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File a claim

If you do not have all information on hand, please indicate this in the “Comments” section at the end of this form.

Your claim

Your claim will be processed based on the type of insurance you have.

Identify which of the following apply to your situation:

Sick leave (disability)
Accidental fracture
Accidental dismemberment or loss of use of a limb
Hospitalization or home health care expenses
Paramedical costs resulting from an accident
Are you filing this claim for yourself?
This email address will be used to contact you in regard to this claim. You will receive a confirmation of receipt for your claim.

Identification of the person who will follow-up with the claim (this person will receive communication regarding the claim and must send us required documents as needed)

This email address will be used to contact you in regard to this claim. You will receive a confirmation of receipt for your claim.

Did you know that using a valid email address speeds up the processing of your claim? Information will be sent by mail to the policyowner.

Can you provide the insurance policy number(s) related to this claim? This information will help us to speed up the processing of your claim.
Providing the policy number helps speed up the claim process.
The policy number (7 to 10 digits) is usually found in the top right corner of your policy document.

File a claim

If you do not have all information on hand, please indicate this in the “Comments” section at the end of this form.

About you About
Postal box or rural route Postal box or rural route
Date of birth
(excluding overtime)
About your sick leave (disability) About ’s sick leave (disability)
Sick leave start date
Maximum of 5,000 characters 0 character(s)
Is the disability the result of an accident?
Date of the accident
Maximum of 5,000 characters 0 character(s)
Have you returned to work? Has the insured returned to work?
During your disability period, did you do any work for which you received compensation (light duties, temporary assignment, etc.)? During the disability period, did the insured do any work for which he received compensation (light duties, temporary assignment, etc.)? During your disability period, did you do any work for which you received compensation (light duties, temporary assignment, etc.)? During the disability period, did the insured do any work for which he received compensation (light duties, temporary assignment, etc.)?
Start date
End date (if applicable)
Date of return to work
Anticipated date of return to full-time work (if known)
Were you hospitalized? Was the insured hospitalized?
Date admitted
Date released (if applicable)
About your accidental fracture About ’s accidental fracture
Date of the incident causing the fracture
Maximum of 5,000 characters 0 character(s)
Is the fracture caused by a motorized vehicle accident?
Were you driving at the time of the accident? Was the insured driving at the time of the accident?
Check all that apply:
About your loss-of-use of a limb or loss of sight About ’s loss-of-use of a limb or loss of sight
Is the loss-of-use of a limb or loss of sight the reason for your disability? Is the loss-of-use of a limb or loss of sight the reason for the insured's disability?
Date of the incident causing the loss-of-use of a limb or loss of sight
Maximum of 5,000 characters 0 character(s)
Date of the incident causing the loss-of-use of a limb or loss of sight
Maximum of 5,000 characters 0 character(s)
Is the loss-of-use of a limb or loss of sight caused by a motorized vehicle accident?
Were you driving at the time of the accident? Was the insured driving at the time of the accident?
Was a specialist consulted?
Supporting document and comments
No supporting documents are required at this time. We will contact the policyowner as needed.

Providing a copy of this document will help speed up the processing of your claim.

Providing a copy of these documents will help speed up the processing of your claim.

Providing a copy of this document will help speed up the processing of your claim.

  • Hospitalization summary indicating the duration and reason
  • Invoices for claimed home health care expenses (if applicable)
  • Radiology report
  • Doctor’s note indicating the date, cause and nature of the loss of use
  • Invoices for claimed paramedical costs
  • Medical document indicating the date, cause and diagnosis
  • Statement of reimbursement from another insurer (if applicable)

Do you have these documents? Send them now.
Is a document missing? Request it as soon as possible. Doing so will help you avoid slowing down the claim review process. Do you have this documents? Send it now.
Is the document missing? Request it as soon as possible. Doing so will help you avoid slowing down the claim review process.

Add document
Maximum of 5,000 characters 0 character(s)

Information summary

If you do not have all information on hand, please indicate this in the “Comments” section at the end of this form.

Your claim

Sick leave (disability)
Yes No

Accidental fracture
YesNo

Accidental dismemberment or loss of use of a limb
YesNo

Hospitalization or home health care expenses
YesNo

Paramedical costs resulting from an accident
YesNo

Insurance policy number

Are you filing this claim for yourself?
Yes No

First and last name

Email

Email
I don’t have an email address

I want the benefit paid into another account. Please send me the direct deposit authorization form.
Yes No

Modify

About you About

First and last name

Date of birth

Address

Primary phone

Secondary phone

Email

Email
I don’t have an email address

Job position

Number of weekly working hours at time of disability

Modify

About your sick leave (disability) About ’s sick leave (disability)

Sick leave start date

Physician's diagnosis

Is the disability the result of an accident?
No

Is the disability the result of an accident?
Yes

Date of the accident

Description of accident

Have you returned to work? Has the insured returned to work?
Yes

Date of return to work

Type of return to work

Anticipated date of return to full-time work (if known)

Have you returned to work? Has the insured returned to work?
No

During your disability period, did you do any work for which you received compensation (light duties, temporary assignment, etc.)? During the disability period, did the insured do any work for which he received compensation (light duties, temporary assignment, etc.)?
Yes No

Start date

End date (if applicable)

Were you hospitalized? Was the insured hospitalized?
Yes No

Date admitted

Date released (if applicable)

Modify

About your accidental fracture About ’s accidental fracture

Date of the incident causing the fracture

Details of the incident

Is the fracture caused by a motorized vehicle accident?
Yes No

Were you driving at the time of the accident? Was the insured driving at the time of the accident?
Yes No

Health care facility where you were taken (if applicable) Health care facility where the insured was taken (if applicable)
,

Health care facility where you were treated (if applicable) Health care facility where the insured was treated (if applicable)
,

Which bone was fractured?

Modify

About your loss-of-use of a limb or loss of sight About ’s loss-of-use of a limb or loss of sight

Is the loss-of-use of a limb or loss of sight the reason for your disability? Is the loss-of-use of a limb or loss of sight the reason for the insured's disability?
Yes No

Date of the incident causing the loss-of-use of a limb or loss of sight

Details of the incident

Date of the incident causing the loss-of-use of a limb or loss of sight

Details of the incident

Is the loss-of-use of a limb or loss of sight caused by a motorized vehicle accident?
Yes No

Were you driving at the time of the accident? Was the insured driving at the time of the accident?
Yes No

Health care facility where you were taken (if applicable) Health care facility where the insured was taken (if applicable)
,

Health care facility where you were treated (if applicable) Health care facility where the insured was treated (if applicable)
,

Was a specialist consulted?
Yes No

Last name
,

Modify

Supporting document and comments

Comments

Supporting document

Modify
Declaration

Information summary

Your claim

Sick leave (disability)
Yes No

Accidental fracture
YesNo

Accidental dismemberment or loss of use of a limb
YesNo

Hospitalization or home health care expenses
YesNo

Paramedical costs resulting from an accident
YesNo

Insurance policy number

Are you filing this claim for yourself?
Yes No

First and last name

Email

Email
I don’t have an email address

I want the benefit paid into another account. Please send me the direct deposit authorization form.
Yes No

Modify

About you About

First and last name

Date of birth

Address

Primary phone

Secondary phone

Email

Email
I don’t have an email address

Job position

Number of weekly working hours at time of disability

Modify

About your sick leave (disability) About ’s sick leave (disability)

Sick leave start date

Physician's diagnosis

Is the disability the result of an accident?
No

Is the disability the result of an accident?
Yes

Date of the accident

Description of accident

Have you returned to work? Has the insured returned to work?
Yes

Date of return to work

Type of return to work

Anticipated date of return to full-time work (if known)

Have you returned to work? Has the insured returned to work?
No

During your disability period, did you do any work for which you received compensation (light duties, temporary assignment, etc.)? During the disability period, did the insured do any work for which he received compensation (light duties, temporary assignment, etc.)?
Yes No

Start date

End date (if applicable)

Were you hospitalized? Was the insured hospitalized?
Yes No

Date admitted

Date released (if applicable)

Modify

About your accidental fracture About ’s accidental fracture

Date of the incident causing the fracture

Details of the incident

Is the fracture caused by a motorized vehicle accident?
Yes No

Were you driving at the time of the accident? Was the insured driving at the time of the accident?
Yes No

Health care facility where you were taken (if applicable) Health care facility where the insured was taken (if applicable)
,

Health care facility where you were treated (if applicable) Health care facility where the insured was treated (if applicable)
,

Which bone was fractured?

Modify

About your loss-of-use of a limb or loss of sight About ’s loss-of-use of a limb or loss of sight

Is the loss-of-use of a limb or loss of sight the reason for your disability? Is the loss-of-use of a limb or loss of sight the reason for the insured's disability?
Yes No

Date of the incident causing the loss-of-use of a limb or loss of sight

Details of the incident

Date of the incident causing the loss-of-use of a limb or loss of sight

Details of the incident

Is the loss-of-use of a limb or loss of sight caused by a motorized vehicle accident?
Yes No

Were you driving at the time of the accident? Was the insured driving at the time of the accident?
Yes No

Health care facility where you were taken (if applicable) Health care facility where the insured was taken (if applicable)
,

Health care facility where you were treated (if applicable) Health care facility where the insured was treated (if applicable)
,

Was a specialist consulted?
Yes No

Last name
,

Modify

Supporting document and comments

Comments

Supporting document

Modify
Need help?

Do you have questions about your claim?

1-844-442-4636

Contact the Customer Service Department