Universal Loan Insurance Claim - Statement Of Claimant (Page 2 of 2) in pdf

Universal Loan Insurance Claim - Statement Of Claimant Page 2

11. HOSPITALIZATION

a) Were you hospitalized for this condition?

¨ Yes

¨ No

b) If so, list all the hospitalizations you had related to your present disability.

NAME AND ADDRESS OF HOSPITAL

DATE OF HOSPITALIZATION

REASON

12. PHYSICIANS List all the physicians you consulted for your present disability.

NAME AND ADDRESS OF PHYSICIAN

DATE OF CONSULTATION

REASON

13. MEDICAL HISTORY List the physicians you consulted and the hospitalizations you had during the last 2 years.

NAME AND ADDRESS OF PHYSICIAN OR HOSPITAL

DATE OF CONSULTATION AND/OR HOSPITALIZATION

REASON

14. OTHER REVENUES

Are you claiming benefits from any other source? ¨ Yes

¨ No

If so, please indicate from which source:

¨ Worker’s Comp. – WSIB, WCB

¨ Private or Government Automobile Insurance

¨ CPP ILLNESS

¨ CPP RETIREE

¨ Crime Victim Compensation Program (CVCP)

¨ EMPLOYMENT INSURANCE – Illness

¨ EMPLOYMENT INSURANCE

¨ Other sources, such as insurance companies or other, please indicate

15. Have you performed tasks related to your job since the beginning of your disability? ¨ Yes

¨ No

If so, when?

⏐⎯d ⎯⏐⎯ m ⎯⏐⎯ ⎯ y ⎯ ⎯⏐

What kind of work?

16. I have returned to work or I might return to work :

¨ Yes

¨ No

¨ Part-time from

⏐⎯d ⎯⏐⎯ m ⎯⏐⎯ ⎯ y ⎯ ⎯⏐

¨ Regular tasks or ¨ Modified tasks, please specify:

¨ Full-time on

⏐⎯d ⎯⏐⎯ m ⎯⏐⎯ ⎯ y ⎯ ⎯⏐

¨ Regular tasks or ¨ Modified tasks, please specify:

I hereby certify to the best of my knowledge that the statements made above are complete and true.

Insured’s Signature : _____________________________________________________ Date : _________________________________

09/07 (07/12)

Universal Loan Insurance Claim - Statement Of Claimant Page 2

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