Claim And Authorization Form printable pdf download

Claim And Authorization Form

CLAIM AND AUTHORIZATION FORM

CLAIMANT INFORMATION – TRIP INTERRUPTION

Full Last Name:

First Name:

Date of Birth:

Address:

City:

Province:

Postal Code:

Home Phone:

Day Time Phone:

E-mail Address:

CLAIM AND TRIP INFORMATION

Departure Date:

Return Date:

Diagnosis:

Describe the circumstances which resulted in the interruption of your trip:

Date of the cause of interruption:

Medical history may be required to fully review your claim. Please provide your Canadian physician(s) information below.

Family Physician(s):

Telephone:

Walk-in Clinic (if applicable):

Telephone:

Canadian Specialist(s):

Telephone:

LIST OF SUBMITTED EXPENSES

Original Receipts

Description of your Out-of-Pocket Expenses

Date Incurred

Amount

Currency

Enclosed Y/N

* Please attach another sheet if your expenses exceed the space provided

* If your expenses are in more than one currency, please total each separately

Total Amount: ______________

Currency:___________

Total Amount: ______________

Currency:___________

Payment Direction (all payments are made by cheque in Canadian Funds)

Although I am the insured person on this policy, I authorize RBC Insurance Company of Canada to pay the benefits under this claim to the

following person: (I understand that if this section is not completed, I will receive the amount payable)

Name:

Address:

Claim And Authorization Form