Policy Number __/__/__/__/__/__/ - __/__/__/__/__/__/__/__/__/
Policyowner Name (please print)
Phone Number: Home Work
Policyowner’s Signature Date
FOR DENTIST’S USE ONLY, FOR ADDITIONAL INFORMATION, DIAGNOSIS,
PROCEDURES, OR SPECIAL CONSIDERATION.
SIGNATURE OF PATIENT (PARENT/GUARDIAN)
UNIQUE NO. SPEC. PATIENT’S OFFICE ACCOUNT NO.
LAST NAME GIVEN NAME
CITY PROV. POSTAL CODE
SIGNATURE OF POLICYOWNER
DATE OF SERVICE
DAY MO. YR.
THIS IS AN ACCURATE STATEMENT OF SERVICES PERFORMED
AND THE TOTAL FEE DUE AND PAYABLE, E. & O.E.
TOTAL FEE SUBMITTED
1. Patient’s relationship to you: 2. Patient’s date of birth:
If Yes, name of school?
b) If Yes, how many hours worked per week?
If Yes, name of family member insured
If Yes, name of other insurance company Policy number
b) If Yes to question 5 a), and the patient is a dependent child, please provide spouse’s date of birth
If Yes, give date, location, and explain how accident happened.
If No, give date of prior placement and reason for replacement.
Day Month Year
Day Month Year
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Canadian Life and Health
All claims under this plan are submitted by the policyowner.
We may exchange personal information about claims with the
policyowner and a person acting on his or her behalf when
necessary to confirm eligibility and to mutually manage the
1. Have your dentist complete Part 1.
2. Policyowner completes Parts 2 and 3.
3. If you wish benefits to be paid directly to the dentist, sign
the assignment portion of Part 1 above. Assignment of
benefits is irrevocable.
Life may discuss details of
this claim with the assignee.
4. Send this claim to:
The Canada Life Assurance Company
Individual Health Unit
PO Box 6000
Winnipeg MB R3C 3A5
For inquiries call: 1-866-430-2863
PART 1 DENTIST
I HEREBY ASSIGN MY BENEFITS
PAYABLE FROM THIS CLAIM TO THE
NAMED DENTIST AND AUTHORIZE
PAYMENT DIRECTLY TO HIM/HER.
I UNDERSTAND THAT THE FEES LISTED IN THIS CLAIM MAY NOT BE COVERED BY OR MAY EXCEED MY
BENEFITS. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO MY DENTIST FOR THE ENTIRE
TREATMENT. I ACKNOWLEDGE THAT THE TOTAL FEE OF $ IS ACCURATE AND HAS BEEN
TO ME FOR SERVICES RENDERED.
I AUTHORIZE RELEASE OF THE INFORMATION CONTAINED IN THIS CLAIM FORM TO MY INSURING
COMPANY/PLAN ADMINISTRATOR. I ALSO AUTHORIZE THE COMMUNICATION OF INFORMATION RELATED
TO THE COVERAGE OF SERVICES DESCRIBED IN THIS FORM TO THE NAMED DENTIST.
PART 2 POLICYOWNER INFORMATION
At Canada Life, we recognize and respect the importance of privacy. Personal information that we collect will be used for the purposes of assessing
your claim. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect
to service providers), write to Canada Life’s Compliance Officer or refer to www.canadalife.com.
I authorize Canada Life, any healthcare provider, my plan administrator (if applicable), other insurance or reinsurance companies, administrators of government
benefits or other benefits programs, other organizations, or service providers working with Canada Life located within or outside Canada, to exchange personal
information when necessary for these purposes. I certify the information given is true, correct and complete to the best of my knowledge.
This claim will be returned to you if it is incomplete or contains errors. Please keep a copy for your records.
PART 3 PATIENT INFORMATION
3. If the patient is a child, does the patient reside with you? Yes No
4. If the patient is a child over 18 but under 25 years of age:
a) Is he/she a full-time student? Yes No
Is he/she employed? Yes No
5. a) Are you or any other member of your family entitled to benefits from any other source? Yes No Group Individual
6. Is treatment required as a result of an accident? Yes No
7. If claim is for denture, crown or bridge, is this an initial placement? Yes No
© The Canada Life Assurance Company, all rights reserved. Any modification of this
document without the express written consent of Canada Life is strictly prohibited.