IMPORTANT – PLEASE READ
Before completing this form, please review the checklist below and select the boxes that apply to your situation:
q If you purchased your trip from a travel agency in Quebec:see with your financial institution if there are specific instructions relating to this particular situation.
q Have you requested a refund or a credit from your service provider (wholesaler, carrier, lodging etc.)?
q Have you included the following documents to your request?
COVID-19
CLAIM FORM – TRIP CANCELLATION INSURANCE
01CAN0082E (07-20 V2)
Spouse last name First name
Other claimants (other than the cardholder)
PAGE 1 OF 2
Primary Credit Cardholder Information
Gender
M F
Date of birth
Year Month Day
Email
Telephone 1
Telephone 2
Is the cardholder submitting a claim?
Yes No
First name
Gender
M F
Gender
M F
Gender
M F
Gender
M F
Dependant child last name First name
Group Insurance:
Other Travel Insurance:
Tavel Insurance with a Credit Card Company:
Other Insurance
Name
Financial Institution First 7 digits of the card Last 3 digits of the card
File number (optional)
Date of birth
Year Month Day
Date of birth
Year Month Day
Date of birth
Year Month Day
Date of birth
Year Month Day
Mailing address
No Street Apt. City Province Postal code
Dependant child last name First name
Dependant child last name First name
Identification number
Financial institution
Card number
Insurance Company
Policy number
Do you or does your spouse or child have another travel insurance?
Company phone number
Policyholder
Cardholder
Policy number
Policyholder
Insurance Company
Yes No If so, please provide the following information.
Have you already initiated a claim? Yes No If so, please indicate the file number:
q
This claim form FULLY completed and signed
q
Proof of cancellation issued by your travel service provider(s)
q
Copies of all refunds, credits and reimbursements
q
Detailed invoices from your travel service provider(s) including their
cancellation policies
q
q
q
Proof of payment for the trip (such as a credit card or banking
statement)
Airline tickets (if applicable)
Direct payment form completed and signed (if applicable)
PAGE 2 OF 2
Date the trip was purchased
Date the trip was cancelled
with the travel provider
Cost of trip $
Amount claimed $
IMPORTANT – Required information to process your claim
Was the trip purchased from a travel agency in the province of Quebec?
If " Yes", have you submitted and received a reponse from the OPC?
Yes No
Yes No
If you answered " Yes" to both questions, please attach a copy of the decision rendered by the OPC
Original return date
Planned destination (city and country)
Have you obtained a credit or refund from your service provider(s)?
Yes No
If " Yes", please attach a copy of the service provider’s answer and ensure the details of the refunds and credits received are listed in the table below
Ex. : Vacation package ABC wholesaler $1,000 $250 $750$
Expenses & Fees Claimed (paid with your credit card)
$ $ $
$ $ $
$ $ $
$ $ $
$
Agreement, Authorization, and Subrogation
SEND THE DULY COMPLETED FORM ALONG WITH ALL OTHER REQUIRED DOCUMENTS TO CANASSISTANCE
By email:
claims@canassistance.com
Send all scanned documents and keep all originals for at least 1 year
following submission of your claim.
By regular mail:
CanAssistance, Travel Claims Department
1981, McGill College Avenue, Suite 400, Montreal, Quebec H3A 2W9
COVID-19
CLAIM FORM – TRIP CANCELLATION INSURANCE
Year Month Day
Year Month Day
Original departure date
Year Month Day
Year Month Day
Fee description
Trip provider
(supplier, carrier, online purchase, etc.)
Amount paid (CAD)
Reimbursement and credits
already received (CAD)
Claimed amount
(CAD)
1. I hereby certify that I have not received any compensation for this loss giving rise to this claim other than that declared in this form.
2. I certify that I have not in any way caused or attempted to cause, directly or indirectly, this loss. I have not concealed or misrepresented any circumstances or any
relevant facts regarding this coverage and its purposes.
3. I hereby agree to assign to CanAssistance Inc. all benefits payable by third parties for losses covered under the policy. Furthermore, following the application for
reimbursement from CanAssistance Inc., I authorize third parties to pay CanAssistance Inc., the benefits payable regarding these losses.
4. To assess my application for benefits, I authorize insurance companies, airline companies, travel agents and any other organization or person who have information
about me or the loss leading to my claim, to convey that information to CanAssistance inc. Further, I authorize CanAssistance inc. to provide my information to the insurer
of my travel policy and to its reinsurers, to internal and external auditors and to any professional or organization mandated by CanAssistance inc. within the context of my
claim.
5. I declare that the information and details given on this form and the information provided in the attached documents are complete and true, and I am aware that any
false declaration shall nullify the insurance certificate or insurance policy and shall result in the denial of my application for benefits.
6. In consideration of the benefits to be paid as per my policy, I hereby assign and subrogate to my insurer, my rights and remedies against anyone and any person who
may be responsible or liable for amounts, damage, loss and/or injuries suffered by me and/or one or more of my family members, covered under my contract, up to all
the amounts that will be paid by my insurer and thus hereby subrogate my insurer in all my rights and remedies for the said amounts.
7. I agree to accept no settlement without the prior approval of my insurer, failing which all amounts paid by my insurer will be reimbursed to it without delay, and I agree
and accept to reimburse my insurer any amount that I receive from anyone and any person who may be responsible or liable for such amounts, damage, loss and/or injury
or from any person liable for it, up to the amount paid by my insurer.
Date :
Signature of Policyholder or legal heir :
Signature of Spouse if he or she is claiming :
Signature of the dependant, if she or he is of legal age :
Date :
Date :
0
IMPORTANT NOTICE
REQUEST FOR PAYMENT BY DIRECT DEPOSIT
TRAVEL INSURANCE
Policyholder Identification
Bank Account Details (Canadian financial institutions only)
If your claim is deemed admissible, by default a cheque will be sent to the policyholder. If you prefer to receive the reimbursement in
your chequing account through the direct deposit option, please complete this form or attach a sample void cheque.
We recommend that you select direct deposit for a number of reasons:
Avoid the many possible days that come with receiving cheques by mail.
Access your funds immediately without any holds that may be required by your financial institution.
You should be aware that no method of transmission over the Internet or method of electronic storage can be guaranteed to be 100%
secure.
01CAN0081E (07-20 V2)
Contract or certificate number
Name of policyholder
Signature of policyholder
Date day / month / year
I hereby request that my benefits be paid via electronic funds transfer (direct deposit) into the aforementioned account number.
1. Cheque No.—not required
2. Branch No.—5 digits
3. Institution No.—3 digits
4. Account No.—as shown on your cheque (up to
12 digits)
Cheque No.
Branch No.
Account No.
By email:
claims@canassistance.com
By regular mail:
CanAssistance, Travel Claims Department
1981, McGill College Avenue, Suite 400, Montreal, Quebec H3A 2W9
click to sign
signature
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