Fill - Free fillable Scotiabank Scotia Mortgage / Line of Credit Protection PDF form

Scotiabank

Scotia Mortgage / Line of Credit Protection Claim Package

Important:

Before submitting your claim for consideration, please refer to your Scotia Mortgage or Scotia Line of Credit Protection Certicate of

Insurance which outlines the policy provisions, limitations and restrictions.

• Please ensure ALL documents are fully completed for the type of Scotia Mortgage or Scotia Line of Credit Protection benet you are

claiming. Missing documents may delay the assessment of your claim.

For Life claims: Please note a completed Attending Physician’s Statement is required in addition to a copy of the Proof of Death

certificate. This is required to etablish the cause of death. A copy of a Coroner’s report can also be provided.

For Terminal Illness claims: Please note a Terminal Illness is an illness that has been determined by a Doctor in writing to likely

result in death within one year of the diagnosis date.

For Critical Illness claims: Please ensure your physician has included with the Attending Physician’s Statement the medical reports

and test results that are required to support the diagnosis and date diagnosed. The Attending Physician’s Statement outlines the

required documents.

For Disability claims: Please note that if your claim is beyond the 150 day submission period, you may be required to provide at

your own expense additional medical reports to support the period of disability. In such cases, we suggest submitting your Attending

Physician’s Statement, along with copies of your medical chart records that are dated throughout the period of time you are claiming

benefits. If insured with another disability carrier, providing a copy of your claim file may be sufficient to support your period of claim.

For Disability benefits, if approved, benefits are payable to Scotiabank and become due following a 60 day qualifying period starting

on the first loan payment due date following the end of your qualifying period. The claim payment will be pro-rated if a Disability

benefit is payable for a portion of a regular payment. No benefits are payable for the qualifying period. Frequency of payment is

based upon your regular Mortgage account payment due date or your regular monthly payment due date for Lines of Credit. There

is a 24 month maximum benefit for any one period of disability and a 48 month lifetime maximum.

• For Life and Terminal Illness claims, if approved, the benet is a lump sum benet payable to Scotiabank once the claim assessment

is complete.

• Upon receipt of the initial claim forms and initial review, Canada Life will advise you in writing of your claim status and/or if any

additional information is required to complete the claim assessment.

• Until a claims decision has been reached, you are responsible for maintaining the required payments with Scotiabank.

• The completed claim package, required medical documents and the Financial Loan Statement provided to you by the bank can be

forwarded to:

Canada Life Assurance Company

Creditor Insurance Ofce - Halifax

PO Box 158, Station M

Halifax NS B3J 3V2

Or faxed to: 902.423.8169 or 1.844.223.2766

Or emailed to: HalifaxCreditor@canadalife.com

For inquiries regarding the completion of the forms, please contact us at 1.800.387.2671.

328-CI CAN-2/18

document without the express written consent of Canada Life is strictly prohibited.

Page 1 of 5

® Registered trademark of The Bank of Nova Scotia, used under license. ScotiaLife Financial is the brand name

for the Canadian insurance business of The Bank of Nova Scotia and certain of its Canadian subsidiaries.

328-CI CAN-2/18

document without the express written consent of Canada Life is strictly prohibited.

Scotia Mortgage / Line of Credit

Protection

Statement of Claim

INSURED INFORMATION: (PLEASE PRINT)

Mr. Mrs. Ms.

First Name: Last Name: Date of Birth:

(mm/dd/yyyy)

Mailing Address:

(Street and Number)

City/Town: Province: Postal Code:

Home Telephone No.: - Mobile Telephone No.: -

Email Address:

Name and Address of the Insured’s General Practitioner:

Name and Address of any other physicians or hospitals consulted by Insured:

CLAIM TYPE:

Life Critical Illness Terminal Illness Disability

FOR LIFE CLAIMS: (PLEASE PRINT)

Mr. Mrs. Ms.

Name of Person Claiming: Relationship to Deceased:

Date of Death of the deceased:

(mm/dd/yyyy)

Mailing Address:

Telephone No.: -

Email Address:

NOTE: If no family physician has been indicated above for the insured, please provide name and address of any known physicians or

walk in clinics the deceased may have consulted. In some cases, Provincial Medical Records may be required upon receipt of the claim.

Name of Physician / Walk in Clinic:

Address:

Name of Physician / Walk in Clinic:

Address:

Name of Physician / Walk in Clinic:

Address:

Please continue to back of this form and complete Signature of Authorization section.

Mortgage

Policy

Mortgage

Number

Mortgage Balance Owing

(not required for Disability claims)

Line of Credit

Policy

Line of Credit

Number

Line of Credit

Balance Owing

$ $

(Please Print)

Page 2 of 5

® Registered trademark of The Bank of Nova Scotia, used under license. ScotiaLife Financial is the brand name

for the Canadian insurance business of The Bank of Nova Scotia and certain of its Canadian subsidiaries.

■

FOR DISABILITY, CRITICAL ILLNESS OR TERMINAL ILLNESS CLAIMS

- 3rd Party Authorization: (PLEASE PRINT)

If you wish to designate a representative to correspond and/or make claim on your behalf with Canada Life, please complete the

information below. I understand that Canada Life will exchange my personal information with my representative to the same extent

they would with me, personally.

Mr. Mrs. Ms.

Name of Representative:

Address: Relationship:

Telephone No.: -

Name of Insured: Signature of Insured:

(Please print)

Date:

FOR DISABILITY CLAIMS: (PLEASE PRINT)

Last day worked: (mm/dd/yyyy) Date returned to work: (mm/dd/yyyy)

Expected date of return to work: (mm/dd/yyyy)

Date illness/injury became disabling:

Date placed off work by a medical doctor:

Cause of Disability: Sickness Accident

Accident Location: Home Work Elsewhere (specify):

How did the accident happen?

Have you ever had same or similar condition? Yes No

If yes, describe:

If disability is due to a motor vehicle accident, provide the following information:

Were you a: Driver Passenger

If Driver, were you under the influence of alcohol/substance? Yes No

Were any charges laid? Yes No

Are you currently receiving or will you become entitled to receive any benefits by reason of your disability from any of the following:

Workers’ Compensation Board Canada or Quebec Pension Plan

Other Government Plan (UIC etc.) Any group coverage

Page 3 of 5

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SIGNATURE OF AUTHORIZATION TO OBTAIN INFORMATION - TO BE COMPLETED BY INSURED (or ESTATE if

applicable):

At The Canada Life Assurance Company, we recognize and respect the importance of privacy. When you apply for coverage,

we establish a confidential file that contains your personal information. This file is kept in the offices of Canada Life or the offices of

an organization authorized by Canada Life. You may exercise certain rights of access and rectification with respect to the personal

information in your file by sending a request in writing to Canada Life. Canada Life may use service providers located within or outside

Canada. We limit access to personal information in your file to Canada Life staff or persons authorized by Canada Life who require it to

perform their duties, to persons to whom you have granted access, and to persons authorized by law. Your personal information may

be subject to disclosure to those authorized under applicable law within or outside Canada. We collect, use and disclose the personal

information to administer the group benefits plan, including investigating and assessing your claim.

I authorize Canada Life, my creditor and / or plan sponsor, any healthcare or rehabilitation provider, any insurance or reinsurance

companies, administrators of government benefits or other benefits programs, any person having knowledge of me or my health, and

service providers working with Canada Life or the above to exchange personal information, including consultation reports, when relevant

and necessary for the purpose of administering the group benefits plan including investigating and assessing my claim.

I acknowledge that the personal information is needed by Canada Life to administer the group benefits plan including investigating and

assessing my claim. I acknowledge that my consent enables Canada Life to process my claim and that refusing to consent may result

in delay or denial of my claim.

This consent may be revoked by me at any time by sending a written instruction. I agree that a photocopy of this authorization is as valid

as the original.

Signature of Insured or Authorized Representative: Date:

(please print) (mm/dd/yyyy)

TO BE SIGNED BY INSURED (or ESTATE if applicable):

Note: If signing as an Authorized Representative please confirm the manner of Authorization.(If required, proof of authorization may be

requested).

Executor/Administrator of Estate Power of Attorney Co-Borrower Other

(Please Specify)

Page 4 of 5

document without the express written consent of Canada Life is strictly prohibited.

PLEASE SUBMIT COMPLETED FORM TO: Canada Life Assurance Company

Creditor Insurance Office - Halifax

PO Box 158, Station M

Halifax NS B3J 3V2

Fax to: 902.423.8169 or 1.844.223.2766

Email to: HalifaxCreditor@canadalife.com

328-CI CAN-2/18

PLEASE SUBMIT COMPLETED FORM TO:

The Canada Life Assurance Company

Creditor Claims

PO Box 158, Station M

Halifax NS B3J 3V2

Tel 1.800.387.2671 Fax 1.902.423.8169 or 1.844.223.2766

CLAIM FOR CRITICAL ILLNESS/TERMINAL ILLNESS BENEFITS

ATTENDING PHYSICIAN’S STATEMENT - TO BE COMPLETED BY PHYSICIAN

(ANY FEES FOR THIS INFORMATION MUST BE PAID FOR BY THE CLAIMANT.)

First Name of Patient: Last Name of Patient: Date of Birth:

(MM/DD/YY)

Diagnosis:

Date symptoms first appeared: Exact Date of First Diagnosis:

(MM/DD/YY) (Please include MM/DD/YY)

Has patient ever had the same or similar condition? Yes No

If Yes, state when, if applicable, the duration and describe:

Has the patient been hospitalized? Yes No Length of stay: to

(MM/DD/YY) (MM/DD/YY)

Name of Hospital: Hospital Telephone No.: ( ) -

PLEASE INCLUDE THE MEDICAL DOCUMENTS LISTED BELOW REQUIRED TO SUPPORT THE RELEVANT DIAGNOSIS NOTED FOR THIS

INSURANCE CLAIM.

Physician’s Name

(Please Print)

Signature Date

Address:

Telephone No.: ( ) - Fax No.: ( ) -

Heart Attack: Attach copies of ECG’s from day of event that confirm evidence of a new heart attack, in addition to the

lab results supporting an elevation of the cardio bio-markers and/or enzymes.

Stroke: Attach copies of diagnostic evidence supporting a Stroke diagnosis and outline the current neurological deficits

resulting from the stroke that have been present in excess of 30 days and are considered to be permanent.

Cancer: Attach copies of the diagnostic evidence to confirm the malignant neoplasm including the initial pathology report.

Paralysis*: Attach detailed neurological findings to clarify extent of paralysis. Please note the paralysis must continue

for at least 180 consecutive days.

Coronary Artery Bypass*: Attach operative or discharge reports confirming Coronary Artery Bypass surgery.

Blindness*: Attach medical evidence from an Ophthalmologist to support permanent and uncorrectable loss of sight in

both eyes with details of visual acuity and field of vision.

Deafness*: Attach medical evidence from an Otolaryngologist or ENT to support permanent hearing loss in both ears,

with copies of relevant audiograms.

Coma*: Attach medical evidence by a Neurologist clarifying level of consciousness. Please note coma must persist for at least

96 consecutive hours.

Terminal Ilness*: Attach medical details of the patient’s medical condition concluding that life expectancy is less than

12 months from the date of diagnosis.

Page 5 of 5

328-CI CAN-2/18

* Please note: These Critical Illnesses are not covered on policies issued after June 2011. Please consult your Certificate

of Insurance to confirm.

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