Student Group Accident Insurance Plan Form- Claimant'S Statement

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STUDENT GROUP ACCIDENT INSURANCE PLAN –
CLAIMANT’S STATEMENT
For rapid processing of your request, please send the duly
Life and Health Claims
Telephone
completed form. It will be returned to you if any information
1080 Grande Allée West
Quebec City region: 418 684-5000, ext. 5332
PO Box 1907, Station Terminus
Elsewhere: 1 888 715-5232
is missing.
Quebec City, QC G1K 7M3
Step 1
CLAIMANT
INSTRUCTIONS: The claim form, original invoices and other proof must be
(policyholder, father, mother or guardian)
submitted within 90 days following the date of the accident. Follow the steps
below. The claimant must have Step 3 signed by the university’s authorized
Contract no.:
Undergrad
Grad/Postgrad
representative. Sign the authorization in Step 6 and mail the documents to the
address indicated above. In all cases involving death, dismemberment or loss
University:
____________________________________________________________________________
of use and disability, contact the Company at the numbers indicated above.
Claimant’s name:
____________________________________________________________________
Certain accidents may be covered by a private or government organization
Address:
______________________________________________________________________________
such as the CSST, SAAQ, RAMQ, and IVAC. You must submit your claim to
Street
City
that organization first and forward a copy of the settlement to us.
__________________________________________________________
Province
Postal code
Telephone:
Step 2
IDENTITY OF THE INJURED PERSON
Y
M
D
Name:
Date of birth:
Sex:
M
F
Step 3
DESCRIPTION OF THE ACCIDENT AND RESULTING INJURIES
Y
M
D
Date of the accident:
Is the accident the result of playing in an elite sport activity?
Yes
No
Attach the accident report or personal summary
.
(place, injury) (Add a dated and signed sheet if needed)
__________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________
Signature of the authorized representative of the university:
____________________________________________________________________________________________________
Transportation: Indicate the number of kilometres travelled in the 24 hours following the accident:
_______________________________________________________
Step 4
DOCUMENTS REQUIRED FOR DENTAL CARE
(To be completed by the dentist)
Documents required: • Attach X-rays
• Dentist’s standard dental care form
Dentist’s statement
Y
M
D
The injuries described above were caused by an accident that took place on:
Name or position of the tooth damaged during the accident:
________________________________________________________________________________________________
Nature of the injury:
________________________________________________________________________________________________________________________________________________________
State of the tooth before the accident (if the tooth was whole and sound). Specify:
____________________________________________________________________
Dentist’s name:
Dentist’s address:
_____________________________________________________________
___________________________________________________________
Dentist’s signature:
___________________________________________________________
Step 5
DOCUMENTS REQUIRED
(The claimant is responsible for having the required forms completed at their own expense.)
Before submitting a claim, verify that the benefit and/or the protection are covered under the contract.
Fracture
Radiologist’s report
Physiotherapist/Chiropractor/Other specialists
Original receipts and form provided by the person who administered the treatment
(See policy.)
Transportation by ambulance
Complete original invoice
Other fees
Original invoice
Step 6
DECLARATION AND AUTHORIZATION
Are you covered by another insurance plan (employer or other insurance)?
Yes
No
Company:
Contract No:
The claim must be submitted to the company offering
_______________________________________________
_______________________________________________
the insurance first, and a copy of the settlement must
be forwarded to us along with copies of the invoices.
Name of insured:
Certificate No:
_____________________________________
_______________________________________________
Are the benefits under this claim covered by this insurance?
Yes
No
I hereby certify that all of the information provided herein is true to the best of my knowledge and that all expenses were incurred by me (or my dependents) for the
exclusive use of the aforementioned person. To evaluate my claim, I authorize any healthcare professional, health organization or any other public or private
organization that has personal information about me or my family to disclose this information to Industrial Alliance Insurance and Financial Services Inc. or its authorized
representative. A photocopy of this authorization shall be as valid as the original.
Date:
Claimant’s signature:
_______________________________
_________________________________________________________________________________
F13-175A-5(10-12) PDF

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