Hospitalization Insurance Claim - Insured'S Sured'S Statement Statement
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1
2Hospitalization Insurance Claim
Hospitalization Insurance Claim
In In sured’s
sured’s Statement
Statement
5055, M
B
. E
, S
202, M
, Q
H1R 1Z7 T
:514-327-00201-800-465-5818 F
: 514-327-9313
ETROPOLITAIN
LVD
AST
UITE
ONTREAL
UEBEC
EL
AX
Police No.
Effective date
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯ ⎯
Y
⎯ ⎯⏐
INSTRUCTIONS
A.
F
I
’
S
ILL OUT THE
NSURED
S
TATEMENT
B.
H
. T
I
AVE THE ATTENDING PHYSICIAN FILL OUT THE OTHER SIDE
HE
NSURED IS RESPONSIBLE FOR ANY RELATED CHARGES
C.
SEND THE PROOF OF STAY OF HOSPITALIZATION
D.
30
RETURN THIS FORM TO THE COMPANY WITHIN
DAYS OF ADMISSION TO HOSPITAL
IDENTIFICATION OF THE INSURED
First and last name
Date of birth
Social Insurance Number
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯ ⎯
Y
⎯ ⎯⏐
Address
Profession or occupation
Work tel. :
Home tel. :
Were you staying in a health care facility before your
If so, indicate facility name and address
hospitalization ?
Yes
No
INFORMATION REGARDING HOSPITALIZATION
Hospital name and address
Date of admission
Release date
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯
Y
Y
⎯ ⏐
⎯ ⏐
Were you treated in the intensive care unit ?
If so, state duration of stay in the intensive care unit
Yes
No
Did you undergo surgery ?
If so, indicate date and nature of surgery
Yes
No
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯
Y
⎯ ⏐
Name and address of physician who treated you
Name and address of your family physician
Was the hospitalization caused by :
If illness, specify
an accident
an illness
Date illness
Have you had this type of illness
If so, when
began
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯
before?
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯
Y
⎯ ⏐
Y
⎯ ⏐
Yes
No
More specifically, were you treated or did you take any medication in relation to the cause of the hospitalization in the 12
months prior to the effective date of this insurance? If so, indicate the dates and the name of the attending physician.
Yes
No
Name of physician : _____________________________________________________________________________________________
Date(s) : _______________________________________________________________________________________________________
TO BE FILLED OUT IN THE CASE OF ACCIDENT
Date of accident
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯
Time of accident
Y
⎯ ⏐
Specify type
car accident
work-related accident
fall
other
Exact location(s)
Injuries
Explain in detail how the accident occurred
I declare that the above answers are complete and true
Date
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯
Insured’s signature
Y
⎯ ⏐
Important
Important
AUTHORIZATION
AUTHORIZATION
I
,
,
I
,
,
HEREBY AUTHORIZE ANY ORGANIZATION
HOSPITAL
PHYSICIAN OR OTHER PERSON WHO HAS
HEREBY AUTHORIZE ANY ORGANIZATION
HOSPITAL
PHYSICIAN OR OTHER PERSON WHO HAS
,
,
,
,
TREATED OR EXAMINED ME TO COMMUNICATE
AT ANY TIME
ANY INFORMATION THAT SUCH
TREATED OR EXAMINED ME TO COMMUNICATE
AT ANY TIME
ANY INFORMATION THAT SUCH
PERSON OR ORGANIZATION MAY HOLD CONCERNING MY HEALTH OR MY MEDICAL HISTORY TO
PERSON OR ORGANIZATION MAY HOLD CONCERNING MY HEALTH OR MY MEDICAL HISTORY TO
T
E
, L
I
C
I
.,
.
T
E
, L
I
C
I
.,
.
HE
XCELLENCE
IFE
NSURANCE
OMPANY
NC
OR ITS REPRESENTATIVES
HE
XCELLENCE
IFE
NSURANCE
OMPANY
NC
OR ITS REPRESENTATIVES
⎯⏐⎯ m ⎯⏐⎯ ⎯
⎯⏐⎯ m ⎯⏐⎯ ⎯
D
:
D
:
D
Y
D
Y
ATE
⏐⎯
⎯ ⎯⏐
ATE
⏐⎯
⎯ ⎯⏐
I
’
: _____________________________________
I
’
: _____________________________________
NSURED
S SIGNATURE
NSURED
S SIGNATURE
(}
)
OTHER SIDE
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