Universal Loan Insurance Claim - Statement Of Claimant
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1
2UNIVERSAL LOAN INSUR ANCE CLAIM
UNIVERSAL LOAN INSUR
ANCE CLAIM
STATEMENT OF CLAIMAN T T
STATEMENT OF CLAIMAN
5055 Metropolitain East, suite 202, Montreal, Quebec H1R 1Z7 – Tel.: 514-327-0020 – 1-800-465-5818 – Fax : 514-327-9313
o
Claim N
: ___________________________________
o
Name in full
: __________________________________________________________
Policy N
: __________________________________
¨ Male
¨ Female
Address :_____________________________________________________________________ Telephone (residence) : ________________________________
Street
⏐⎯d ⎯⏐⎯ m ⎯⏐⎯ ⎯ y ⎯ ⎯⏐
_____________________________________________________________________ Date of birth :
City
Province
Postal Code
Name of Employer : ___________________________________________________________ Job Title :____________________________________________
Address : _________________________________________________________________________________ Telephone : ______________________________
Street
City
Province
Postal Code
NECESSARY REQUIREMENTS IN ORDER TO CLAIM
IMPORTANT –
,
:
TO AVOID US ASKING FOR ADDITIONAL INFORMATION CONCERNING ADMISSIBLE LOANS
FOR EACH SEPARATE LOAN
1.
E
:
NCLOSE A COPY OF THE CONTRACT STATING
Ø
INITIAL DATE OF LOAN
Ø
INITIAL AMOUNT OF LOAN
Ø
EXPIRATION DATE OF LOAN
Ø
MONTHLY AMOUNT TO BE PAID
2.
E
.
NCLOSE A STATEMENT OF ACCOUNT INDICATING THE REMAINING BALANCE AT THE TIME OF THE DISABILITY
O
LIST OF ADMISSIBLE LOANS
NAME OF FINANCIAL INSTITUTION
LOAN OR CONTRACT N
o
Mortgage loan
o
Line of credit
o
Leveraged loan to finance an investment
o
Renovation loan
o
Personal loan
o
Car/boat/motorcycle loan (rental or purchase)
o
Student loan
o
Any other loan with a fixed period and regular
payments, excluding credit cards
INFORMATION PERTAINING TO CLAIM
1. What is the cause of your disability?
________________________________________________________________________________________________
2. What are the disabilities as to your usual work
? ______________________________________________________________________________________
____________________________________________________________________________________________________________________________________
3. ACCIDENT
4. SICKNESS
3.1) Where and how did the accident occur? ___________________
4.1) What were the first symptoms? __________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
st
4.2) At what date did you notice these symptoms for the 1
time?
3.2) Date of accident?
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3.3) What were the first symptoms? ___________________________
3.
_____________________________________________________
________________________________________________________
5. What was your regular professional occupation prior to your disability? _______________________________________________________
A. Is it seasonal work ? ¨ Yes
¨ No
If so, what is the yearly normal period of work ? From
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to
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6. Your last day at work is:
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7. Date of last paid worked day or illness day:
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8. Date which you have consulted a physician for the first time for this condition:
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9. Since when are you continuously and totally disabled?
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10.Have you ever suffered from the same condition or a similar one?
¨ Yes
¨ No
so, when?
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If
other side
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