Group Critical Illness Claim Form Page 2
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3PLEASE CHECK THE BOX(S) THAT BEST DESCRIBE YOUR CLAIM
Following are the benefits available under your Group Critical Illness Policy. Please check the benefit(s) you believe may be
due based upon your condition. You will need to attach medical record documentation of your condition.
CRITICAL ILLNESS BENEFIT (Please check the illness which you are requesting benefits)
*Medical record documentation by psychiatrist or neurologist
Alzheimer’s Disease
Benign Brain Tumour
*Pathology report
Carcinoma In Situ
*Pathology report
Invasive Cancer
*Pathology report
*Medical documentation showing state of unconsciousness for 14 or more
Coma
consecutive days
Deafness
*Medical documentation showing diagnosis of total hearing loss in both ears
*Medical documentation by ophthalmologist showing permanent loss of sight to
Blindness
20 degrees or less in both eyes or corrected visual acuity or 20/200
Coronary Artery By-Pass Surgery
*Medical record or billing proof of procedure
*Medical record documentation showing proof of failure to both kidneys and proof
Kidney Failure
of dialysis or transplant
*Electrocardiograph proof and lab reports showing elevated cardiac biochemical
Heart Attack
markers
*Medical documentation showing diagnosis of the loss of muscle function of 2 or
Paralysis
more limbs without severance
*Medical documentation by a neurologist showing inability to perform 2 or more
Parkinson’s Disease
daily living activities
Stroke
*Medical record documentation of permanent neurological deficit
Major Organ Failure (Transplant or
*Billing proof of procedure or proof of being enrolled in transplant centre
Waiting List
Multiple Sclerosis
*Medical record documentation showing diagnosis of multiple sclerosis
Aortic Surgery
*Medical record or billing proof of procedure
*Medical documentation showing diagnosis of third degree burns over at least
Severe Burns
20% of the body
*Medical documentation showing diagnosis of total loss of ability to speak for at
Loss of Speech
least 180 days
WELLNESS BENEFIT
SIGN THIS PART ONLY IF YOU WISH TO ASSIGN YOUR BENEFITS TO A PROVIDER OR A FACILITY
I request that Allstate Insurance Company of Canada send benefits to someone other than me. Please send benefits available to the name and address
shown below:
Name
Relationship
Address
Provider or Facility Identification Number
City
Province
Postal Code
Signature of Insured
Date
AICC10365
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