Fillable TRIP CANCELLATION AND INTERRUPTION EXPENSES STATEMENT (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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TRIP CANCELLATION AND INTERRUPTION EXPENSES STATEMENT (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Page 1 of 4
Plan Number I.D. Number Plan Name
Last Name First Name
Address City Province Postal Code
Telephone Home Telephone Work
( ) ( )
Employee’s Signature: Date:
Dependent First Name Last Name Date of Birth
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M7468-9/19
© The Canada Life Assurance Company, all rights reserved. Any modification of this
document without the express written consent of Canada Life is strictly prohibited.
TRIP CANCELLATION AND INTERRUPTION
EXPENSES STATEMENT
Please complete all sections of this form and mail to Canada Life, Attention: Out-of-Country Claims Department
PO Box 6000 Winnipeg MB R3C 3A5
When submitting your claim be sure to include all of the following required documentation:
• Proof of originally scheduled trip (for example: trip itinerary, “e” or paper tickets).
• If applicable, proof of new scheduled trip (for example: trip itinerary, “e” or paper tickets).
• Itemized invoice(s) and proof of payment(s) for trip(s) and/or other claimed expenses.
• Statement from travel agent/ supplier indicating whether a refund and/or credit voucher has been issued. If no
refund and/or credit is available, provide a copy of the cancellation terms and conditions indicating why one is not
available.
• Any other supporting documentation showing the reason trip was cancelled/interrupted/extended, including a
death certicate (if loss is due to death).
• If claiming medical expenses, complete the Out-of-Country claim form, along with the appropriate provincial
authorization and assignment form located on www.canadalife.com.
Section A: Employee Information
At Canada Life, we recognize and respect the importance of privacy. Personal information that we collect will be used for
the purposes of assessing you claim and administering the group benets plan. 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 Ofcer or refer to www.canadalife.com.
I authorize Canada Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies,
administrator of government benets or other benets 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 certify that the information given is true, correct and complete to the best of my knowledge.
Section B: Dependent Information (only complete if claim is being submitted on behalf of a dependent)
Section C: Trip Details
Section D: Type of Loss
Please indicate the general nature of the loss being claimed:
Trip Cancellation Trip Interruption Trip Extension
Name and address of sick, injured or deceased person’s usual Family Physician:
Name and address of any other Physician who may have treated the sick, injured or deceased person in the last
12 months:
Section E: Statement of Expenses Claimed
Type of Expense Incurred Date Incurred Amount Paid Currency
Amount Reimbursed by
Travel Agent/Supplier
Purpose of Trip Destination
Scheduled Departure Date Actual Departure Date (if applicable)
Scheduled Return Date Actual Return Date (if applicable)
□ □ □
Date trip was cancelled with the travel Agent/Supplier:
If the loss is due to sickness, please provide details of the illness:
Date symptoms rst appeared: Date of rst medical consultation:
Date condition was diagnosed:
If loss is due to accident, please describe how the accident occurred:
Date of Accident:
If loss is due to death, please conrm the cause of death:
Date of Death:
If the loss is due to other circumstances, please provide details:
Date the loss rst occurred:
Name of sick, injured or deceased person:
Your relationship to sick, injured or deceased person:
Name:
Address: City: Province: Postal Code:
Name:
Address: City: Province: Postal Code:
Page 2 of 4
Page 3 of 4
If no, please provide explanation why:
(Signature)
Patient’s First Name Last Name Date of Birth
Diagnosis/condition resulting in claim Date symptoms first appeared Date of first medical consultation
Date investigative/diagnostic testing began Date condition was diagnosed Date the patient was assessed as unfit to travel
Date patient was advised not to travel
Section F: Statement of Other Coverage
Are you or any other member of your immediate family entitled to travel benets under any other plan, including
coverage through employment, individual/private plans or credit card plans that will cover or has covered a portion of
this claim? Yes No
If ‘Yes’, please provide the following information:
Type of other
coverage (group,
individual, credit
card) Name and address of other coverage carrier Phone Number
Policy or Plan
Number I.D. Number
Have you sent a claim and/or otherwise contacted the other carrier about this claim? Yes No
If ‘Yes’, please attach a copy of their settlement or denial.
Please sign the following statement if you have other insurance. This allows us to coordinate the payment of your claim
with other insurance carriers. This statement must be signed before your claim can be assessed.
I hereby authorize Canada Life and its agents to coordinate
the payment of benefits with any other insurance carriers which may also have liability for this claim. I hereby irrevocably
direct Canada Life to make payments, receive payments and negotiate settlements with carriers on my behalf.
I further authorize Canada Life to release and/or receive medical information from providers and other carriers for
facilitate the payment and coordination of this claim.
Section G: Medical Certificate
This section is to be completed and signed by the licensed medical physician who treated the sick, injured or deceased
person, resulting in this claim. Any fees for the completion of this form is the claimant’s responsibility and are not cov-
ered by your Canada Life plan.
Has the patient suffered from this medical condition in the past?
Yes No
If ‘Yes’, please list below the patient’s history of this condition and other related conditions:
Date of Consultation Symptoms Exhibited/Diagnosis Treatment Rendered
Was the condition related to alcohol, misuse of drugs, or self-inicted injury? Yes No
Was the condition related to pregnancy? Yes No
If ‘Yes’, please conrm the following details:
Was the patient hospitalized? Yes No
If ‘Yes’, please conrm the following detail:
Are you the patient’s usual family physician? Yes No
If ‘No’, please provide the name, address and telephone number for patient’s usual family physician:
Please also provide the name, address and telephone number of any other physician who treated the patient, or referred
the patient to you:
I certify that the information provided in this section is complete, true and accurate to the best of my knowledge and belief.
Section G: Medical Certificate (continued)
□ □
If ‘Yes’, please provide details:
□ □
Date of Last Menstrual Period: Expected Delivery Date:
□ □
Name of Hospital: Admission Date: Discharge Date:
□ □
Name: Phone #: ( )
Address: City: Province: Postal Code:
Name: Phone #: ( )
Address: City: Province: Postal Code:
Physician’s Signature: Date:
Physician’s Name (please print): Phone #: ( )
Address: City: Province: Postal Code:
Page 4 of 4
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TRIP CANCELLATION AND INTERRUPTION EXPENSES STATEMENT (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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