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Plan name
Plan number Plan member I.D. number
Plan Member Name
First name Last name
Plan Member Address
Number and street City or town Province Postal code
Date of birth:
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Number and street City or town Province Postal code
Number and street City or town Province Postal code
Number and street City or town Province Postal code
Number and street City or town Province Postal code
Day Month Year
Page 1 of 2 PLEASE COMPLETE PAGE 2 OF STATEMENT
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Last Name First Name
3. If the patient is a dependent child, please provide spouse’s date of birth:
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If yes, please provide: Canada Life plan number ID Number
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Day Month Year
Date:
Plan Member signature X
Day Month Year
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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M7463-2/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
Pre-treatment / Estimate for
Continuous Glucose Monitor (CGM)
To be submitted with initial CGM estimates only
Charges for completing this form or providing medical
information are not covered by your plan.
INSTRUCTIONS
1. Complete page 1 and 2 of this form in full.
2. Plan member to complete parts 1 through 5, Physician to complete part 6
3. Attach estimate and retain copies for your files as originals will not be returned.
4. Send to the appropriate Benefit Payment Office for your plan. See Part 7.
PART 1 - Confirmation, Authorization and Signature
I certify that the information given on this claim form is true, correct and complete to the best of my knowledge. I certify that all goods and services being claimed have
been received by me, my spouse and/or my dependents; and that my spouse and/or dependents are eligible under the terms of my plan.
The submission of fraudulent claims is a criminal offence. Canada Life takes the submission of fraudulent claims seriously. Suspected fraudulent claims may be reported
to your employer or plan sponsor and to the appropriate law enforcement agency.
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 and
administering the group benefits plan. I authorize Canada Life, any healthcare or dentalcare provider, my plan administrator, 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 understand that personal information may be subject to disclosure to those authorized under
applicable law within or outside Canada.
I also consent to the use of my personal information for Canada Life and its affiliates’ internal data management and analytics purposes.
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 Chief Compliance Officer or refer to www.canadalife.com.
PART 2 - Plan Member Information You must complete this section fully. If you are unsure of your plan name, plan number or plan member
I.D. number, please contact your plan administrator.
Language preference:
English French
PART 3 - Coordination of Benefits Complete this section to indicate whether you or any member of your family have benefits coverage
from any other plan.
1. Are you, or any member of your family, entitled to benefits under any other plan for the expenses being claimed? Yes No
If yes, please answer the questions below.
2. Who does the other insurance belong to?
Self Spouse Child
4. Is the other insurance also with Canada Life?
Yes No
5. Is treatment required as the result of an accident?
Yes No
If yes, what kind of accident? Motor Vehicle If other, please explain.
