Fillable Life Claim Kit INSTRUCTIONS FOR COMPLETION AND REQUIREMENTS (OTIP RAEO)

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Life Claim Kit INSTRUCTIONS FOR COMPLETION AND REQUIREMENTS (OTIP RAEO)

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Page 1 of 8
LIFECLAIMKIT OTIP 02/17
MISCELLANEOUS REQUIREMENTS
Payments to minor beneficiary
ORIGINAL or NOTARIZED copy of Court Appointment of Guardianship of the Estate of the Minor
Payments to estate
ORIGINAL or NOTARIZED copy of the Probated Will or Letters of Administration for proceeds $50,000 and over
Beneficiary has died before the insured member
ORIGINAL or NOTARIZED/CERTIFIED copy of the deceased Beneciary’s Proof of Death
MAIL COMPLETED FORMS TO OTIP:
OTIP Group Life and Disability Claims
125 Northeld Drive West
PO Box 218
Waterloo ON N2J 3Z9
If you have any questions, please contact OTIP Group Life and Disability Claims at 1-800-267-6847.
Insured Member Life Claim (please print all answers)
Complete pages 2-4 of this form
• Claimant completes and signs pages 2-4
Please check for the following requirements:
Proceeds UNDER $300,000
Original or notarized copy of Funeral Director’s
Statement of Death, and newspaper death report or
obituary notice (if available)
OR
Attending Physician’s Statement (Life Claim), pages 5-6
of this form
Proceeds $300,000 and OVER
Original or notarized copy of Provincial Death Certicate
OR
Attending Physician’s Statement (Life Claim), pages 5-6
of this form
Accidental Death
Attending Physician’s or Coroner’s Statement for
Accidental Death (pages 7-8 of this form)
Dependant Life Claim (please print all answers)
Complete pages 2-4 of this form
• Insured member completes and signs pages 2-4
Please check for the following requirements:
Proceeds UNDER $300,000
Original or notarized copy of Funeral Director’s
Statement of Death, and newspaper death report or
obituary notice (if available)
OR
Original or notarized copy of Provincial Death Certicate
Proceeds $300,000 and OVER
Original or notarized copy of Provincial Death Certicate
OR
Attending Physician’s Statement (Life Claim), pages 5-6
of this form
Accidental Death
Attending Physician’s or Coroner’s Statement for
Accidental Death (pages 7-8 of this form)
Life Claim Kit
OTIP Group Life and Disability Claims
125 Northfield Drive West
PO Box 218
Waterloo ON N2J 3Z9
1.800.267.6847 | www.otip.com
INSTRUCTIONS FOR COMPLETION AND REQUIREMENTS
Reset
Page 2 of 8
LIFECLAIMKIT OTIP 02/17
Fax completed forms to 1-877-205-6847 or mail to OTIP:
OTIP Group Life and Disability Claims
125 Northeld Drive West
PO Box 218
Waterloo ON N2J 3Z9
If you have any questions, please contact OTIP Group Life and Disability Claims at 1-800-267-6847.
To be completed by the person(s) claiming the Life Insurance Benefit. Please print.
1. Deceased Identication
Name: First ____________________________________ Initial ______________ Last _________________________________________
Policy Number: ____________________________________ Location (Class): __________________________________________________
Date of Death: (mm/dd/yyyy) ________________________ Cause of Death: __________________________________________________
Relationship to Insured Member: Insured Member Spouse Child
2. If Insured Member was disabled prior to death, was any claim for disability benets led?
Yes No
If yes, please provide claim number, and name of insurance company:
Claim Number: ____________________________________ Insurance Company: ______________________________________________
3. If death was accidental, please complete the following questions:
Date of Accident: (mm/dd/yyyy) _____________________
Where did the accident happen? Home Work Elsewhere (Specify) ___________________________________
If motor vehicle accident, was the deceased the driver? Yes No
How did the accident happen? Please give the complete description. (If insufcient space, please attach a separate
sheet to this form.)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
CLAIMANTS’ STATEMENT
Page 3 of 8
LIFECLAIMKIT OTIP 02/17
Claimant(s) Information (To be completed by each Claimant)
1. Claimant’s Identification
Name: First ____________________________________ Initial ______________ Last _________________________________________
Address: ____________________________________________________________________________________________________________
City: _____________________________________________ Province: ______________ Postal Code: ______________________________
Telephone Number: ________________________________ Social Insurance Number: __________________________________________
Relationship to the deceased (Named Beneciary, Trustee, Executor, etc.) __________________________________________________
Date of Birth (If over legal age, state “over legal age”): (mm/dd/yyyy) _______________________________________________________
2. Claimant’s Identification (if more than one Claimant)
Name: First ____________________________________ Initial ______________ Last _________________________________________
Address: ____________________________________________________________________________________________________________
City: _____________________________________________ Province: ______________ Postal Code: ______________________________
Telephone Number: ________________________________ Social Insurance Number: __________________________________________
Relationship to the deceased (Named Beneciary, Trustee, Executor, etc.) __________________________________________________
Date of Birth (If over legal age, state “over legal age”): (mm/dd/yyyy) _______________________________________________________
3. Claimant’s Identification (if more than two Claimants)
Name: First ____________________________________ Initial ______________ Last _________________________________________
Address: ____________________________________________________________________________________________________________
City: _____________________________________________ Province: ______________ Postal Code: ______________________________
Telephone Number: ________________________________ Social Insurance Number: __________________________________________
Relationship to the deceased (Named Beneciary, Trustee, Executor, etc.) __________________________________________________
Date of Birth (If over legal age, state “over legal age”): (mm/dd/yyyy) _______________________________________________________
CLAIMANTS’ STATEMENT (CONTINUED)
Page 4 of 8
LIFECLAIMKIT OTIP 02/17
Declaration (To be signed by each Claimant)
I certify that the information in this form, and any further verbal or written statement provided by me in the future, is true and complete
to the best of my knowledge.
I agree that my claim may be denied as a result of my providing false, incomplete, or misleading information.
I hereby claim the life insurance proceeds payable as a result of the death of the deceased, _____________________________________ .
I understand that OTIP and its insurer will investigate this claim and may require information related to the deceased’s health,
employment, police investigations, and autopsy, or coroner’s inquest reports (collectively referred to in this authorization
as “Information”).
I authorize any person or organization who has Information pertaining to this claim, including any employer, plan administrator,
plan sponsor, health care professional, health care institution and any other medically-related facility, insurer, police, coroner and
investigative agency, to release and exchange Information requested by OTIP and its insurer for the purposes of benets plan
administration and investigation and management of this claim (“Purposes”).
I authorize OTIP, its insurer and their reinsurers and/or service providers to collect, to use, to maintain and to disclose to the persons
or organizations listed above and/or each other any Information needed for the Purposes.
I authorize the use of my Social Insurance Number for tax reporting.
I agree that a photocopy or electronic version of this authorization is valid.
I understand that OTIP’s Privacy Policy is available at www.otip.com or by request.
Claimant’s Signature: ________________________________________________Date: (mm/dd/yyyy) ________________________________
Claimant’s Signature: ________________________________________________Date: (mm/dd/yyyy) ________________________________
Claimant’s Signature: ________________________________________________Date: (mm/dd/yyyy) ________________________________
Any Information provided to or collected by OTIP in accordance with this authorization, will be kept in a benets health le. Access to
the Information will be limited to:
w OTIP employees, OTIP’s representatives, OTIP’s insurer and their reinsurers and service providers in the performance of their jobs;
w Persons to whom you have granted access; and
w Persons authorized by law.
You have the right to request access to the personal information in your le, and, where appropriate, to have any inaccurate
information corrected.
CLAIMANTS’ STATEMENT (CONTINUED)
Page 5 of 8
LIFECLAIMKIT OTIP 02/17
PLEASE COMPLETE THE FOLLOWING INFORMATION
1. Deceased Identification
Name: First ____________________________________ Initial ______________ Last _________________________________________
Date of Death: (mm/dd/yyyy) ________________________ Residence at Death: _______________________________________________
Place of Death (If Hospital or Institution, Give Name):_____________________________________________________________________
____________________________________________________________________________________________________________________
Age at Death or Date of Birth: (mm/dd/yyyy) _____________________________________________________________________________
2. Cause of Death
(Enter only ONE cause for each of A, B and C) Interval between onset and death:
A) Disease or condition directly leading to death (This does not A)
mean the mode of dying such as Heart Failure, Asthenia, etc. It
means the disease, injury or complication which caused death):
Antecedent causes (Morbid conditions, if any, giving rise to
the above cause. State the underlying cause last):
B) Due to or as a consequence of: B)
C) Due to or as a consequence of: C)
Other signicant conditions (contributing to the death but not related to the disease or condition causing death):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
The Claimant is PERSONALLY responsible for ALL EXPENSES RELATED TO the completion of this form.
Attending Physician’s Statement
(Life Claim)
OTIP Group Life and Disability Claims
125 Northfield Drive West
PO Box 218
Waterloo ON N2J 3Z9
1.800.267.6847 | www.otip.com
Page 6 of 8
LIFECLAIMKIT OTIP 02/17
3. Medical History of Deceased
Date of rst attendance in last illness: (mm/dd/yyyy) ______________________________________________________________________
Date of last attendance in last illness: (mm/dd/yyyy) ______________________________________________________________________
If death was due to accident, homicide or suicide, specify which. Describe briey:
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Was an inquest held? Yes No
Was an autopsy performed? Yes No
If so, by whom and with what ndings?
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Have you treated or advised the deceased during the last 3 years, prior to last illness? Yes No
Did the deceased, to your knowledge, receive treatment during the last 3 years from any other
physician, or in a hospital or institution?
Yes No
If “Yes” to either question, please furnish the following:
Name of Physician: __________________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________
Nature of illness or injury: ___________________________________________________ Date: (mm/dd/yyyy) ________________________
4. Declaration
I certify that the information in this form, and any further verbal or written statement provided by me in the future concerning
this claim, is true and complete to the best of my knowledge. I understand that the information in this form will be kept in a
benets health le relating to this claim and might be accessible by third parties to whom authorized access has been granted.
I acknowledge and agree that by signing this document I consent to the unedited disclosure of any information contained
herein, to OTIP and its insurer.
Attending Physician’s Full Name: ______________________________________________________________________________________
Degree or Qualication:_______________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________
City: _____________________________________________ Province: ______________ Postal Code: ______________________________
Attending Physician’s Signature: _____________________________________________ Date: (mm/dd/yyyy) ________________________
ATTENDING PHYSICIAN’S STATEMENT (LIFE CLAIM) (CONTINUED)
Page 7 of 8
LIFECLAIMKIT OTIP 02/17
Attending Physician’s or Coroner’s
Statement for Accidental Death
OTIP Group Life and Disability Claims
125 Northfield Drive West
PO Box 218
Waterloo ON N2J 3Z9
1.800.267.6847 | www.otip.com
PLEASE COMPLETE THE FOLLOWING INFORMATION
1. Deceased Identication
Name: First ____________________________________ Initial ______________ Last _________________________________________
Date of Injury: (mm/dd/yyyy) _________________________ Date of Death: (mm/dd/yyyy) _______________________________________
2. What was the precise nature and extent of the injury? ____________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
3. What was the primary or immediate cause of death? _____________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
4. Was the deceased ever treated for a similar condition? Yes No
If “Yes”, where and by whom? ________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
5. Was there any contributing or remote causes of death? Yes No
If “Yes,” what were they? _____________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
6. Was the injury, described above, by itself and independent of all causes, sufcient to cause of death? Yes No
If “No,” please explain fully. ___________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
The Claimant is PERSONALLY responsible for ALL EXPENSES RELATED TO the completion of this form.
Page 8 of 8
LIFECLAIMKIT OTIP 02/17
7. At the time of the injury, was the deceased under the inuence of alcohol or narcotic drugs? Yes No
If “Yes,” please show blood alcohol content and/or type of drug.
Blood Alcohol Content: _____________________________ Type of Drug: _____________________________________________________
8. Was an autopsy performed?
Yes No
9. Declaration
I certify that the information in this form, and any further verbal or written statement provided by me in the future concerning
this claim, is true and complete to the best of my knowledge. I understand that the information in this form will be kept in a
benets health le relating to this claim and might be accessible by third parties to whom authorized access has been granted. I
acknowledge and agree that by signing this document I consent to the unedited disclosure of any information contained herein,
to OTIP and its insurer.
Attending Physician’s or Coroner’s Full Name: ___________________________________________________________________________
Degree or Qualication:_______________________________________________________________________________________________
Address: ____________________________________________________________________________________________________________
City: _____________________________________________ Province: ______________ Postal Code: ______________________________
Attending Physician’s or Coroner’s Signature: _________________________________ Date: (mm/dd/yyyy) ________________________
ATTENDING PHYSICIAN’S OR CORONER’S STATEMENT FOR
ACCIDENTAL DEATH (CONTINUED)
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Life Claim Kit INSTRUCTIONS FOR COMPLETION AND REQUIREMENTS (OTIP RAEO)

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Completed 6 January 2021

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