Appeal Request Form Allstate Benefits Canada printable pdf download

Appeal Request Form Allstate Benefits Canada

ALLSTATE INSURANCE COMPANY OF CANADA

HOME OFFICE: MARKHAM, ONTARIO

Administrator: RWAM Insurance Administrators Inc.

49 Industrial Drive

Elmira, Ontario N3B 3B1

APPEAL REQUEST FORM

Please use this form to appeal a denial decision.

Insured’s Name

Certificate No.

Name of representative pursuing appeal, if different from above

Number and Street

Phone No.

City

Province

Postal Code

Type of Denial:

 Denied Claim

 Denied Service

 Other

What specific decision are you appealing?

(Explain what you want our company to pay for)

Explain why you believe the claim or service should be covered:

(Attach additional sheets of paper, if needed.)

If you have questions about the appeals process or require assistance to prepare your

appeal, you may call RWAM Insurance Administrators Inc. at 1-519-725-7118 or toll free

at 1-844-455-6255.

Please submit this form to:

Group CI Claims

RWAM Insurance Administrators Inc.

49 Industrial Drive

Elmira, Ontario N3B 3B1

Please make sure to attach everything that shows why you believe Allstate Benefits should cover your claim,

including:  Medical records  Supporting documentation (letter from your doctor, brochures, notes,

receipts, etc.). THANK YOU!

Signature of insured or authorized representative

Date

PLEASE SEE AUTHORIZATION ON PAGE 2.

Allstate Benefits is a marketing name for Allstate Insurance Company of Canada (home office: Markham, Ontario).

All products are underwritten by Allstate Insurance Company of Canada.

AICC5068

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Appeal Request Form Allstate Benefits Canada