Please print
Policy Number
__/__/__/__/__/__/ - __/__/__/__/__/__/__/__/__/
Policyowner Name (please print)
Policyowner Address
Phone Number: Home Work
If Yes, name of family member insured
Name of other insurance company
Policy number
If Yes, give date, location and explain how the accident happened.
3. If patient is a dependent child, please provide spouse’s date of birth.
/ /
Day Month Year
Policyowner’s Signature Date
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
HEALTHCARE EXPENSES STATEMENT
(Medical, Vision, Drugs)
INSTRUCTIONS: Attach the bills and receipts for all expenses and itemize them by providing all the
information requested.
Note: Drug bills and receipts, other than those required for government drug plans, are
part of our records and will not be returned. Therefore, please retain the itemization of
expenses that will accompany our cheque or explanation for Income Tax purposes.
IMPORTANT: Please answer all questions. This claim will be returned to you if it is incomplete or
contains errors. All claims under this plan are submitted by the policyowner. We may
exchange personal information about claims with the policyowner and/or a person
acting on his or her behalf when necessary to confirm eligibility and to mutually manage
the claims.
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
POLICYOWNER INFORMATION
COORDINATION OF BENEFITS
1. Are you or any other member of your family entitled to benefits from any other source? Yes No Group Individual
2. Is treatment required as the result of an accident? Yes No
DEPENDANT INFORMATION
Patient Name
Relationship
to Policyowner
Date of Birth
Year Month Day
Does patient
reside with you?
YES NO
Full-Time
Student?
YES NO
If child over 18 years
If student, how
many hours
per week?
Employed?
YES NO
How many
hours worked
per week?
CLAIM DETAILS (If additional space is needed, attach a separate page)
DRUG EXPENSES
OTHER EXPENSES
Patient Name Number of
Receipts
Total Charge
Type of Expense Nature of Illness Total Charge
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.
M635D(IHP)-9/19
© The Canada Life Assurance Company, all rights reserved. Any modification of this
document without the express written consent of Canada Life is strictly prohibited.
