Appeal Request Form Allstate Benefits Canada (Page 2 of 2) in pdf

Appeal Request Form Allstate Benefits Canada Page 2

Important: To avoid delay, please sign authorization below.

I hereby authorize any licensed physician, medical practitioner, hospital, clinic, or other medically related facility, insurance company

or other organization, institution or person that has any records or knowledge of me (or my dependents) to give such information to

Allstate Insurance Company of Canada or its designee. This authorization is valid for a period of 24 months from the date signed. I

understand that I may revoke this authorization at any time by notifying Allstate Insurance Company of Canada in writing of my desire

to do so. A photographic copy of this authorization shall be as valid as the original, regardless of date signed. I understand that I or

my representative may receive a copy of this authorization by supplying policy number(s) and Insured’s name in a written request to

the company.

Sign here __________________________________________________ Date:_______________

 Check here if address is new

Claimant

Number and Street:____________________________________________ City:_____________________ Province:_____________

Postal Code: __________ Telephone No. (

)________________

AICC5068

Page 2 of 2

Appeal Request Form Allstate Benefits Canada Page 2