City or town Province Postal code
Number and street Province Postal code
Number and street City or town Postal code
Number and street City or town Province Postal code
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M635D-3/20
© 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.
Healthcare Expenses Statement
INSTRUCTIONS
1. Complete page 1 and 2 of this form in full.
2. Attach receipts for all services and retain copies for your files as original receipts
will not be returned.
3. Send to the appropriate Benefit Payment Office for your plan. See PART 10.
Did you know that most claims can be submitted online,
and you could receive your claim payment faster with
direct deposit?
Go to http://groupnet.canadalife.com for details.
THIS IS A:
Claim for benefits Pretreatment/estimate
All claims under this group benefits plan are submitted through the plan member. We may exchange personal information about claims with the plan member and a person
acting on their behalf when necessary to confirm eligibility and to mutually manage the claims.
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 benefi ts plan. I authorize Canada Life, any healthcare or dentalcare provider, my plan administrator, other insurance or reinsurance companies,
administrators of government benefi ts or other benefi 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 also consent to the use of my personal information for Canada Life and its affi liates’ 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.
Plan Member Name
Plan Member Address
Language preference:
English French
PART 3 - Coordination of Benefi ts Complete this section to indicate whether you or any member of your family have benefi ts coverage from any other plan.
1. Are you, or any member of your family, entitled to insurance 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*
* If the other insurance is not with Canada Life and you have submitted these expenses to your other insurer, please attach the other insurer Explanation of Benefits
(EOB) to this claim. An EOB is required even if no benefits were paid by the other insurance.
5. Is treatment required as the result of an accident?
Yes No
If yes, what kind of accident? Motor Vehicle If other, please explain.
6.
Is a claim being made for Worker’s Compensation Benefits? Yes No
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-
o o
Day Month Year
Plan Member signature X
Date:
Plan name
Plan number Plan member I.D. number
First name Last name
Number and street Number and street City or town City or town ProProvince vince Postal code
Date of birth:
Day Month Year
o o
o o
o o o
First Name Last Name
Day Month
o o
ID Number
o o
o o
o o
Page 1 of 2 PLEASE COMPLETE PAGE 2 OF STATEMENT
3. If the patient is a dependent child, please provide spouse’s date of birth:
If yes, please provide: Canada Life plan number
