Accident Claim Form - Ringette Alberta printable pdf download

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AIG Insurance Company Of Canada

C/o BFL CANADA Risk and Insurance Inc.

145 Wellington Street West

2001McGill College Avenue, # 2200

Toronto, ON M5J 1H8

Montreal, QC, H3A 1G1

Tel: 514-843-3632 F: 514-843-3842 1-800-465-2842

claims@BFLcanada.ca

Accident Claim Form

IMPORTANT:

This claim form must be validated by your Association (section on reverse). Once the claim form

is complete and original itemized invoices attached, mail to BFL Canada within 30 days following the accident.

Insured’s Surname:

Insured’s Given Name:

Address:

Telephone No. (daytime):

Email:

______________________

________________

City/Town:

Province:

Postal Code:

_______________________

Date of Birth (M/D/Y) :

Sex:

Male

Female

______________

1. Date of Accident (M/D/Y) :

Date of Initial Medical attention (M/D/Y):

2. Location and full details of accident and nature of injury sustained :

3. Name of Company who carries your Group Hospital or Medical Insurance:

_____________________________________________________________________ ___

___________________________________ _ _________

4. Name and address of Family Physician :

5. Name and contact information of witness to this accident:

6. Name and address of Surgeons or Specialists who provided treatment regarding this accident:

________________________________________________________________________

PERSONAL INFORMATION NOTICE: I understand that the information provided by me on this claim form and otherwise in respect of my claim, is required by

AIG Insurance Company of Canada, 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.

CERTIFICATION: The statements I provide in completing this claim form and otherwise in respect of my claims 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. 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.

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, benefit plan administrator, federal, territorial or provincial government

department, or any other corporation or organization, institution or association (including obtaining information from the group policyholder or my employer) to

release and exchange with AIG Insurance Company of Canada.

AIG Insurance Company of Canada, or representatives thereof, all personal health information, benefit payment, employment or financial information about me or

any other information or records about me in its possession that is requested while administering my claim. I agree that a reproduction of this authorization shall

be as valid as the original.

Name of Insured’s Parent/Guardian (if under age 18 - print please) :

Signature of Insured or Insured’s Parent/Guardian (if under age 18) :

Date (M/D/Y) : ___________________________________________________________________

Claimant’s Statement – Accident Claim Form (**Please ensure that Page 2 is completed)

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Revised – 10/05/2013