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Policyowner (print full name)
Signature
Date
Patient (print full name)
Signature
Date
If the patient was under age 60 on the policy effective date or its renewal date, please answer the following:
In the entire six month period immediately before leaving his/her home province:
Did the patient experience any new symptoms or an increase in the frequency or severity of symptoms? Yes No
Did the patient require medical attention consultation, diagnosis, treatment or hospitalization? Yes No
Did the patient receive or require oxygen treatment or a change in treatment or medication
(including dosage or usage)? Yes No
If the patient was age 60 or over on the policy effective date or its renewal date, please answer the following:
In the entire 365-days immediately prior to leaving his/her home province:
Did the patient experience any new symptoms or an increase in the frequency or severity of symptoms? Yes No
Did the patient require medical attention, consultation, diagnosis, treatment or hospitalization? Yes No
Did the patient receive or require oxygen treatment or a change in treatment or medication
(including dosage or usage)? Yes No
DECLARATION AND AUTHORIZATION
• I/We authorize any licensed physician, medical practitioner,
hospital or clinic or other medical or medically related facility or
insurance company, to provide to The Canada Life Assurance
Company or any third parties designated by them, any and
all information regarding my or my dependant’s health or
medical history, or treatment, as well as copies of all hospital
or medical records. A photographic copy shall be as valid as
the original.
• I/We certify that the information given is true, correct and
complete to the best of my knowledge.
• I/We further authorize The Canada Life Assurance Company to
release and/or receive medical information from providers and
other carriers to facilitate the payment and coordination of this
claim
• I/We authorize The Canada Life Assurance Company and
any companies or persons designated by them to release any
information regarding me/us to any medical provider or third
parties in or outside Canada. A copy of this original shall be as
valid as the original.
• I/We authorize The Canada Life Assurance Company and its
agents to coordinate the payment of benefits with any other
insurance carriers which may also have a liability for this claim.
• I/We hereby irrevocably direct The Canada Life Assurance
Company to make payments, receive payments and negotiate
settlements with other carriers on the patient’s behalf.
Please forward this form and original receipts to:
The Canada Life Assurance Company
Individual Health Unit
PO Box 6000
Winnipeg MB R3C 3A5
1-866-430-2863
Personal information you provide is kept in strict confidence and will be used to assess your
claim and to administer the benefit plan.
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 their behalf when necessary to confirm
eligibility and to mutually manage the claims.
