SCOTIA CREDIT CARD PROTECTION CLAIM FORM
STATEMENT OF DEATH CLAIMANT STATEMENT
Unity Managing Underwriters Ltd.
P.O. Box 1097, Station B
Willowdale, Ontario, M2K 3A2
T +1.800.668.7092
F +1.416.221.1685
E SCCPClaims@umu.net
Rev.03.21
INFORMATION ABOUT THE DECEASED
Scotia Credit Card No.:
Name of Deceased: Date of Birth: (MM/DD/YYYY)
Address of Deceased:
City: Province: Postal Code:
Cause of Death:
If Accident, state when, where and how:
Date of Death: (MM/DD/YYYY) Onset of Illness: (MM/DD/YYYY)
Prior History of Same or Related Illness Yes No
If yes, describe.
INFORMATION ABOUT THE CLAIMANT
Title: Name: Phone #:
Address:
City: Province: Postal Code:
Email Address:
You are claiming as (please check one box):
Estate Executor/Executrix
Assignee
Other
If other, please specify.
Claimant’s Certification: The above statements are true and complete to the best of my knowledge and belief. In the event of a false or misleading statement in the making of this claim, coverage can be cancelled,
payment of benefits denied and past claims payments recovered without refund of any premiums paid. I agree to refund to the Insurer, the amount of any payments made in the event that such amounts should not
have been paid in respect of my claim.
Privacy Notice: I understand that the information provided by me on this claim form and otherwise in respect of my claim, is required by Chubb Insurance and/or Chubb Life Insurance, its reinsurers and
authorized administrators (the "Insurer") to assess my entitlement to benefits, including but not limited to determining if coverage is in effect, investigating the applicability of exclusions and co-ordinating
coverage with other insurers. For these purposes, the Insurer will also consult its existing insurance files about me, collect additional information about and from me, and where required, collect information
from and exchange information with, third parties. The Insurer will establish a claims file to which access will be restricted to authorized employees and agents of the Insurer and to persons authorized by law.
If I have the right to access the information, access will be given to me or such persons as I may authorize. I understand that in some instances, the employees, service providers, agents, reinsurers, and any of
their providers, of Chubb may be located in jurisdictions outside Canada and my personal information may be subject to the laws of those foreign jurisdictions. I consent to the collection, use, and distribution
of my personal information as may be required for these purposes as of the date of signing of this Claimant Statement and understand that such consent will remain in place until such time as I may revoke it.
To find out more about the Chubb Privacy Policy or our privacy practices please visit chubb.com/ca or send a written request to: Privacy Officer, Chubb, 199 Bay Street - Suite 2500, P.O. Box 139,
Commerce Court Postal Station, Toronto, Ontario M5L 1E2.
Authorization: I authorize, for a period of not less than twelve and not more than twenty-four months from the date hereof, any physician, practitioner, health care provider, hospital, health care institution, medical
organization, clinic and any other medical or medically related facility, any insurance company or reinsurance company, workers compensation board or similar plan or organization, plan administrator, federal,
territorial or provincial government department, or any other corporation or organization, institution or association, to release and exchange with Chubb Insurance/Chubb Life Insurance, or representatives thereof, all
personal health information, benefit payment or financial information about the insured or any other information or records about
the insured in its possession that is requested while administering this claim.
I agree that a photocopy of this authorization shall be as valid as the original.
Claimant’s Signature: Date (MM/DD/YYYY):
Additional Scotia Credit Card No(s):
Title:
By completing and submitting this form,
I agree to all the declarations and attestations made herein. Please submit this form via email to
SCCPClaims@umu.net.
Gender of Deceased:
Male Female
Genderqueer/Non-Binary
Other/Prefer Not to Disclose
Gender
:
Male Female
Genderqueer/Non-Binary
Other/Prefer Not to Disclose
click to sign
signature
click to edit
![]()
