Your Out-Of-Canada Claim Page 2
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3P.O. Box 277
EMERGENCY MEDICAL EXPENSE
Waterloo, ON Canada
N2J 4A4
CLAIM FORM
Please complete, sign and return promptly to Allianz Global Assistance at the address above.
Without this information, we are unable to proceed with your claim.
PATIENT INFORMATION
Patient Name:
Case No.
Address:___________________________________________________ City:_____________________ Province:_______ Postal Code:
Patient’s Date of Birth: ______________________
Male
Female
Patient’s Relationship to Policyholder:
MM/DD/YEAR
Patient’s Provincial Health Card Number (including version code for residents of Ontario):
RWAM Insured Employee & Group Policyholder Information
Employee's Name: _____________________________________________ Date of Birth: ___________________ RWAM Cert No.:___________________
Group/Employer Name: ___________________________________________________________________ RWAM Group No.:______________________
TRAVEL DETAILS
st
Was this your 1
trip outside your home province this year?
Yes
No, this was my _____ stay outside my home province this year.
Departure Date: ____________________ Anticipated/Scheduled Date of Return: ____________________ Actual Return Date: ___________________
MM/DD/YEAR
MM/DD/YEAR
MM/DD/YEAR
Nature of Travel:
Business
Vacation
Study
Medical Care
Other: _________________ Destination: ______________________________
Mode of Travel:
Car
Airplane
Other: ______________ If applicable, was Extension of Coverage purchased?
No
Yes (specify)
___________________________________________________________________________________________________________________________
OTHER INSURANCE INFORMATION
Employer Information
Spouse’s Name:_____________________________________________
If retired, specify name of employer providing benefits:
Spouse’s Date of Birth: ________________________
MM/DD/YEAR
Employer Name: ____________________________________ Retired?
Spouse’s Employer: ______________________________ Retired?
Address: ________________________________________________
Address: ________________________________________________
Phone: _____________________________________________
Phone: _____________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Please indicate all other insurance coverage you have through any other insurer: (i.e. employee/retiree/spousal group benefits, enhanced credit cards,
personal property such as home/auto or any other purchased travel plan). Attach an additional page if required.
1) Name of Insurer: ________________________________________________
Phone: _____________________________________________
Address: __________________________________________________
Lifetime payable limit on policy?
No
Yes (specify) $_____________
Policy No: __________________ Certificate No: _______________________ Signature of Policyholder: ________________________________________
2) Name of Insurer: _______________________________________________
Phone: _____________________________________________
Address: __________________________________________________
Lifetime payable limit on policy?
No
Yes (specify) $_____________
Policy No: __________________ Certificate No: _______________________ Signature of Policyholder: ________________________________________
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
If trip purchased by Credit Card, specify card name: ______________________________ Number: _________________________ Expiry: _________
Have these bills been filed with any other company?
No
Yes If yes, name and contact info: ____________________________________________
COMPLETE PAGE 2
Additional documentation will be required for this claim – see below:
o Original itemized medical bills & prescription receipts if received by patient
o Proof of Departure is required for claims exceeding $1000
o Completed Provincial Health claim forms (only required if you are a
o Photocopy of the patient’s Provincial Health Card
o Accident Report (if applicable)
resident of British Columbia or Newfoundland)
If you have questions, please call Allianz at 1-800-363-1835. Our Customer Service Team can help.
RWAM 02.12
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