Group Critical Illness Claim Form
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3GROUP CRITICAL ILLNESS
CLAIM FORM AND INSTRUCTIONS
If you have any questions regarding benefits available, or how to file your claim, or if you
would like to appeal any determination, please contact the Group CI Claims Department at
1-519-725-7118 or 1-844-455-6255,
8:00 A.M. to 8:00 P.M. Eastern Standard Time or at
The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any
liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.
•
To avoid delays in processing please fill out the sections which apply to your specific claim.
•
Include your certificate number. To obtain your certificate number, you may call
1-519-725-7118 or 1-844-455-6255.
•
You may fax your claim to us at
1-519-669-5135
or scan and electronically submit your claim through
.
•
You may also mail your claim to:
Group CI Claims
RWAM Insurance Administrators Inc.
49 Industrial Drive
Elmira, Ontario N3B 3B1
•
Additional claim forms are available on our website at .
INSURED AND PATIENT INFORMATION
1. Insured’s Name: First:
Middle:
Surname:
E-mail:
Certificate Number:
Date of Birth:
Male
Female
2. Daytime Phone Number: (
)
Evening/Cell Phone Number: (
)
3. Occupation:
PATIENT’S INFORMATION
4. Name: First:
Middle:
Surname:
5. Date of Birth:
Age:
Male
Female
INSTRUCTIONS FOR FILING CRITICAL ILLNESS CLAIMS:
The results of a tissue specimen, culture(s) and/or titer(s) or other diagnostic studies, which initially diagnosed
the critical illness, must accompany your claim. Include a copy of your Attending Physician’s Statement.
Thank You.
AICC10365
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