claim form - air miles · trip cancellation or trip interruption travel delay • trip cancellation...
TRANSCRIPT
NAME OF PHYSICIAN
SIGNATURE OF PHYSICIAN DATE
TELEPHONE( )
D M Y
PHYSICIAN’S STAMP
PATIENT’S NAME
1. PRIMARY DIAGNOSIS (CONDITION WHICH IS THE CAUSE OF THE CLAIM)
2. IS THIS A NEW CONDITION?
3. DATE OF CONSULTATION FOR THE CURRENT ONSET OF THIS CONDITION?
IF YES, PLEASE PROVIDE ALL DATES
IF YES, PLEASE PROVIDE DATES 12. HOW DOES THE ABOVE CONDITION AFFECT THE PATIENT’S ABILITY TO TRAVEL?
EXPLAIN:
YES NO
7. WAS THE MEDICATION ALTERED IN THE PAST 12 MONTHS? YES NO
4. HAS THE PATIENT RECEIVED TREATMENT OR ADVICE FOR THISCONDITION (OR RELATED CONDITION) IN THE LAST YEAR?
8. IF THE PATIENT WAS REFERRED TO YOU, PROVIDE NAME AND PHONE NUMBER OF REFERRING FAMILY PHYSICIAN
YES NO
9a. HAS THE PATIENT BEEN HOSPITALIZED FOR THIS CONDITION(OR RELATED CONDITION) IN THE PAST 12 MONTHS?
YES NO
10. WAS THE CANCELLATION OR INTERUPTION OF THE TRIPDUE TO PREGNANCY?
IF YES, WHAT WAS THE EXPECTED DATE OFDELIVERY?
YES NO
11a. IF THE PATIENT WAS THE INTENDED TRAVELLER: DID YOU ADVISE THE PATIENT NOT TO TRAVEL?
YES NO
11b.ON WHAT DATE WAS THIS CONDITIONSTABLE ENOUGH TO PERMIT THE PATIENTOR FAMILY MEMBER TO TRAVEL?
9b. WERE FOLLOW UP TREATMENTS REQUIRED? YES NO
IF NO, ON WHICH DATE WAS THIS CONDITION FIRST DIAGNOSED?
DATE OF BIRTH
D M Y
D M Y
D M Y
6. DATE MEDICATION FIRST PRESCRIBED?
D
D
M
M
Y
Y
D
D
M
M
Y
Y
D
D
M
M
Y
Y
D
D
M
M
Y
Y
IF YES, PLEASE PROVIDE DATESD
D
M
M
Y
IF YES, ON WHAT DATE?D M Y
Y
D
D
M
M
Y
Y
IF YES, PLEASE PROVIDE DATESD
D
M
M
Y
Y
D
D
M
M
Y
Y
D M Y
D M YD M Y
NAME OF REFERRING FAMILY PHYSICIAN TELEPHONE
( )
AUTHORIZATION AND RELEASE This section must be completed in full by all claimants
CLAIMANT’S STATEMENT This section must be completed if claiming Trip Cancellation, Interruption or any Travel Delay or other travel related expenses
IF CLAIMING MEDICAL EXPENSES
MR/MRSMISS/MS INSURED LAST NAME
GOVERNMENT HEALTH INSURANCE PLAN NUMBER
NO./STREET/APT.
PROVINCE POSTAL CODE HOME TEL. BUSINESS TEL.
CITY
FIRST NAME BIRTH DATE
VERSION CODE
POLICY/CONFIRMATIONNUMBER
IF CLAIMING MEDICAL EXPENSES
MR/MRSMISS/MS INSURED LAST NAME
GOVERNMENT HEALTH INSURANCE PLAN NUMBER
FIRST NAME BIRTH DATE
VERSION CODE
POLICY/CONFIRMATIONNUMBER
1)
2)
D M
M
Y
YD
TRAVELLING COMPANION MR/MRS/MISS/MS LAST NAME FIRST NAME
POLICY/CONFIRMATIONNUMBER
ADDRESS FOR CORRESPONDENCE OR CLAIM PAYMENTS
( ) ( )
DATE OF DEPARTURE
NAME OF PERSON WHO COMPLETED THIS FORM RELATIONSHIP TO CLAIMANT
SIGNATURE OF INSURED / INSURED’S GUARDIAN DATE OF SIGNATURE
DATE CLAIM SUBMITTED
DEPARTURE POINT DESTINATION
DATE OF RETURN DATE OF CAUSE OF CLAIM
SIGNATURE OF CLAIMANT
D M
M M
Y
Y YD D
D M Y
By signing below, I hereby consent to, authorize and direct that Reliable Life InsuranceCompany or its representative may recover from my Government Health Insurance Plan(GHIP) and/or any other Health Insurance carriers or entities, payments which were madeto others on my behalf for out-of-province health services.Furthermore, I agree that, pursuant to any applicable federal, provincial or territorial health insurance legislation as it pertains to freedom of information and protection ofprivacy, I hereby:1. Direct and authorize the Government Health Insurance Plan (GHIP) to make payment
in respect of my claim for out-of-province health services to Reliable Life Insurance Company or its representative, and upon such payment, I hereby release GHIP from any further claim or cause of action in connection with such claim; and
2. Consent to and authorize GHIP to directly or indirectly collect information contained in the claim and source documents pursuant to applicable provincial legislation; and
3. Consent to the disclosure by GHIP to Reliable Life Insurance Company or its representative of such personal information as may be necessarily required to process my claim for out-of-province health services, including the details of any payment previously made directly to me or on my behalf.
Authorization to Physicians, Hospitals, other Health Care Practitioners, Medical Care Facilities, Insurance Carriers, any other Person who has attended or examinedme and Other Sources:I hereby authorize and direct that you release to Reliable Life Insurance Company or its representative, Pottruff & Smith, any and all information you have regarding me, whileunder your professional care, including my medical history, any illness, injury, consultation,medicines or treatment and copies of all hospital and medical records. This authorization will
permit Reliable Life Insurance Company to use the disclosed information for the purpose of determining my eligibility for coverage under my travel insurance policy, assessinginsurance risks, managing my claim and negotiating or settling payments to third parties.This authorization will permit Reliable Life Insurance Company's representative, Pottruff &Smith, to use the disclosed information for the purpose of determining my eligibility forcoverage under my travel insurance policy and processing my claim. I hereby assign toReliable Life Insurance Company any benefits obtained from other sources for lossescovered under this policy. I also direct these sources to forward payment to Reliable LifeInsurance Company for my claims submitted by Reliable Life Insurance Company withregard to these losses. A photocopy, facsimile or electronic copy of this authorization isacceptable. This authorization will also permit Reliable Life Insurance Company to releaseand share information with any or all parties noted above.I certify that the statements and particulars given herein together with those on any accompanying documents are complete, true and correct to the best of my knowledge.I understand the reasons for which I have been asked to consent to the disclosure of my personal information and am aware of the risks or benefits of consenting, or refusingto consent, to the disclosure. I understand that I may revoke this consent at any timeby written notification to Reliable Life and/or its representative Pottruff & Smith. I alsounderstand that the making of false or fraudulent statements in connection with a claim forbenefits may render the certificate of insurance or the policy void.
D M Y
TRIP CANCELLATION/INTERRUPTION/DISRUPTION/TRAVEL DELAYDESCRIBE IN DETAIL THE CAUSE AND CIRCUMSTANCES OF THE TRIP CANCELLATION OR TRIP INTERRUPTION OR TRIP DISRUPTION OR TRAVEL DELAY
ON WHAT DATE WAS THE TRIP BOOKEDWITH AIRMILES®?
DATE OF DEPARTURE
DATE OF RETURNON WHAT DATE WAS THE TRIP CANCELLEDWITH AIRMILES®?
NAME OF SICK/ INJURED/DECEASED PERSON**The Physician's statement must be completed by the attending Physician of the sick/ injured/deceased person
NAME OF THE TRAVEL SPECIALIST WHO CANCELLED THE TRIP
BIRTH DATE DATE OF SICKNESSINJURY OR DEATH
RELATIONSHIP TO THE CLAIMANT
ADDRESS OF SICK/ INJURED/DECEASED PERSON (IF OTHER THAN CLAIMANT) CITY POSTAL CODEPROVINCE TELEPHONE( )
TELEPHONE( )
D D
D
D D
M M
M
M M
M
Y
Y Y
Y
Y
YD
PAGE 1
1b
DATE OF CONSENT
D M YEND DATE OF CONSENT: 12 MONTHS FROM DATE OF SIGNATURE
PHYSICIAN’S STATEMENT FOR TRIP CANCELLATION OR TRIP INTERRUPTION CLAIMSTHIS SECTION MUST BE COMPLETED BY THE ATTENDING PHYSICIAN
CLAIMANT INFORMATION This section must be completed in full by all claimants
DID/WILL YOU RECEIVE ANY REFUNDSFROM ANY OTHER SOURCE?
AMOUNTNO YES
NOTE: THE CLAIMANT IS RESPONSIBLE FOR THE COST OF COMPLETION OF THIS MEDICAL CERTIFICATE PSRL 401 EO4
IF YES, PLEASE PROVIDE NAMES
5. IS THE PATIENT PRESCRIBED MEDICATION(S) FOR THIS CONDITION (OR RELATED CONDITION)?
YES NO
CLAIM FORMCLAIMS WILL NOT BE PROCESSED UNTIL THEREQUIRED SECTIONS HAVE BEEN FULLY COMPLETEDAND SUBMITTED WITH REQUIRED DOCUMENTATION
SUBMIT CLAIM TO:AIR MILES® TRAVEL INSURANCEc/o POTTRUFF & SMITH TRAVEL INSURANCE BROKERS INC.8001 Weston Road, Suite 300Woodbridge, Ontario L4L 9C8Telephone: 1-866-298-6581 Fax: 905-856-1539
IN QUÉBECASSURANCE-VOYAGE AIR MILESmd
a/s POTTRUFF & SMITH COURTIERS d’ASSURANCE VOYAGE INC.83, rue Turgeon, Bureau 300Ste-Thérèse, Québec J7E 3H7Telephone: 1-866-298-6581 Fax: 450-434-5543
1a
AIRMILES/REWARD MILESCASH CLAIMED
AIRMILES/REWARD MILESCASH CLAIMED
MA
KIN
G A
CLA
IM?
DO
CU
ME
NTA
TION
RE
QU
IRE
D:
ME
DIC
AL E
XPE
NS
ES
FOR
CA
NA
DIA
N
RE
SID
EN
TSO
R VIS
ITOR
S TO
CA
NA
DA
1. C
OM
PLETED C
LAIM FO
RM (PAG
E 1)•
CLAIM
ANT IN
FORM
ATION
SECTIO
N•
AUTH
ORIZATIO
N AN
D RELEASE SEC
TION
2.C
OM
PLETED M
EDIC
AL CLAIM
SECTIO
N (PAG
E 2)
3.C
OM
PLETED G
OVERN
MEN
T HEALTH
PLAN SEC
TION
•FO
R RESIDEN
TS OF BRITISH
CO
LUM
BIA OR
SASKATCH
EWAN
- PAGE 2
•FO
R RESIDEN
TS OF Q
UEBEC
- CO
NTAC
T THE C
LAIMO
FFICE FO
R THE Q
UEBEC
(G.H
.I.P.) FORM
•FO
R RESIDEN
TS OF ALL O
THER PRO
VINC
ES -(AU
THO
RIZATION
AND
RELEASE SECTIO
N O
N PAG
E 1)
4.O
RIGIN
AL RECEIPTS FO
R MED
ICAL AN
D O
THER EXPEN
SES
TRIP C
ANC
ELLATION
OR
TRIP IN
TERR
UPTIO
NTR
AVEL DELAY
1. C
OM
PLETED C
LAIM FO
RM (PAG
E 1)•
CLAIM
ANT IN
FORM
ATION
SECTIO
N•
AUTH
ORIZATIO
N AN
D RELEASE SEC
TION
•TRIP C
ANC
ELLATION
OR TRIP IN
TERRUPTIO
N,
TRAVEL DELAY SEC
TION
•PH
YSICIAN
’S STATEMEN
T (C
OM
PLETED BY TH
E PHYSIC
IAN, IF APPLIC
ABLE)
2.U
NU
SED TRAVEL D
OC
UM
ENTS/TRAVEL IN
VOIC
ES/RECEIPTS
3.O
RIGIN
AL DO
CU
MEN
TATION
TO SU
BSTAN
TIATE YOU
RC
AUSE O
F CLAIM
FOR
CLA
IMS U
ND
ER TH
E FOLLO
WIN
G PO
LICY
SECTIO
NS:
TRAVEL A
CC
IDEN
TB
AG
GA
GE
PERSO
NA
L MO
NEY
REN
TAL C
AR
DA
MA
GE
MAILED
TO YO
U IM
MED
IATELY UPO
N REC
EIPT OF
YOU
MU
ST NO
TIFY THE AIR M
ILESC
LAIM O
FFICE. A SEPARATE C
LAIM FO
RM W
ILL BE
CLAIM
NO
TIFICATIO
N.
TRAVEL INSU
RANC
E
MEDICAL CLAIM SECTIONTHE CLAIMANT MUST COMPLETE THIS SECTION IN FULL
CLAIMANT’S STATEMENT This section must be completed if claiming medical expenses
COVERAGE WITH OTHER INSURERS AND OTHER SOURCES This section must be completed in full by all claimants
RESIDENTS OF: BRITISH COLUMBIA THIS SECTION MUST BE COMPLETED PRIOR TO ANY MEDICAL CLAIM PAYMENTS
AUTHORIZATION TO PROVIDE MEDICAL INFORMATION AND ASSIGNMENT OF PAYMENT TO INSURED PERSONOR BENEFICIARY UNDER THE MEDICARE PROTECTION ACT OR HOSPITAL INSURANCE ACT
EXPENSES CANNOT BE PAID UNLES THESE SECTIONS HAVE BEEN COMPLETED IN FULL AND RECEIVED BY THE COMPANY.
GOVERNMENT HEALTH INSURANCE PLAN SECTION (GHIP) AUTHORIZATION & RELEASE
IMPORTANT• BC residents must complete GHIP Authorization and Release section below. • Saskatchewan and Québec residents must contact the Claims Customer Service at 1-866-298-6581 to obtain the appropriate
GHIP Authorization and Release form. • All claimants must complete the Authorization and Release section on the opposite side.
DATED this
BETWEEN of the first part hereinafter referred to as the Assignor
day of, 20
SIGNATURE OFASSIGNOR
ASSIGNMENT:EFFECTIVE FROM TO:
PERSONALHEALTHCARD NO.
WITNESSSIGNATURE OCCUPATION
ADDRESS
CITY PROVINCE POSTALCODE
TELEPHONE ( )
AND RELIABLE LIFE INSURANCE COMPANY C/O POTTRUFF & SMITH TRAVEL INSURANCE BROKERS INC. of the second part, hereinafter referred to as the Assignee8001 WESTON RD, STE. 300, WOODBRIDGE, ONTARIO L4L 9C8
AND HER MAJESTY THE QUEEN IN THE RIGHT OF THE PROVINCE OF hereinafter referred to as the MinisterBRITISH COLUMBIA AS REPRESENTED BY THE MINISTER OF HEALTH
WHEREAS the Assignor is a person eligible for insured services or benefits or both under the Province of British Columbia’s Medicare Protection Act or Hospital Insurance Act or both, and as such may receive payment forthe above services from the Minister.
And WHEREAS the Assignor is under a covenant or obligation under a contract with the Assignee to remit to the Assignee all such payments received for medical services from the Minister.
NOW WITNESSETH THAT in consideration of the said obligation to the Assignee the Assignor hereby assigns unto the Assignee all sums of money that shall be owing to the Assignor by the Minister for the above notedcontract. The Minister is hereby authorized to pay all such sums directly to the Assignee at the address aforesaid, or at any address the Assignee may from time to time designate, with payment of any such sum to besufficient discharge to the Minister of and from any indebtedness in that amount to the Assignor, his heirs, executors, or administrators.
I HEREBY CONSENT TO AND AUTHORIZE THE MINISTRY OF HEALTH TO FURNISH ANY REPRESENTATIVE OF RELIABLE LIFE INSURANCE COMPANY ANY AND ALL RECORDS AND INFORMATION IN THE MINISTRYOF HEALTH’S POSSESSION REGARDING CLAIMS FOR MEDICAL SERVICES INCURRED WHILE I HAD INSURANCE COVERAGE FOR THE ASSIGNMENT PERIOD INCLUDING MEDICAL HISTORY AND PHYSICALCONDITION BOTH PRIOR AND SUBSEQUENT TO RECEIPT OF MEDICAL SERVICES, REGARDLESS OF LAPSED TIME AND BEARING IN ANY WAY ON THE SERVICES RECEIVED DURING THE ABOVE TIME PERIOD.
DESCRIBE IN DETAIL THE CAUSE AND CIRCUMSTANCES OF THE SICKNESS OR INJURY
DATE OF INJURY OR SICKNESS LOCATION OF SICKNESSOR INJURY
CITY COUNTRY
WERE YOUHOSPITALIZED?
YES NO ADMISSIONDATE
DISCHARGEDATE
DATE YOU RETURNEDTO CANADA
DID YOU CONTACT THE ASSISTANCE PROVIDER (24 HOUR SERVICE) AT THE TIME OF THE SICKNESS OR INJURY? NO ASSISTANCEFILE NO.YES
AMOUNTCLAIMED CURRENCY HAS THE BILL
BEEN PAID?NO YES IN
FULLINPART
AMOUNTPAID
GOVERNMENT HEALTHINSURANCE PLAN NUMBER
FULL NAME AS REGISTERED WITHGOVERNMENT HEALTH INSURANCE PLAN
VERSION CODE(ONTARIO RESIDENTS)
NAME OF PARENT OR GUARDIANIF CLAIMANT UNDER AGE 16
NAME OF YOUR SPOUSE (IF APPLICABLE)
FULL NAME OF YOUR USUAL PHYSICIAN IN YOUR PROVINCE OF RESIDENCE
NO./STREET/SUITE NO.
CITY PROV. POSTALCODE TEL. ( )
WERE YOU HOSPITALIZED FOR THIS SICKNESS/INJURY (OR RELATED CONDITION(S)) IN THE LAST 12 MONTHSPRIOR TO THE DEPARTURE DATE SHOWN IN THE POLICY APPLICATION?
CLAIMANT’S (OR PARENT’S)OCCUPATION
NAME OF YOUREMPLOYER
CITY
NAME OF SPOUSE’S EMPLOYER
CITY
YES NO
NO
NO
GROUPPOLICY NO.
POLICY NO.
NAME OFCOVERED PERSON
CARD TYPEBANK
NAME AND ADDRESS OFINSURANCE COMPANY/BROKER
IDENTIFICATIONNO.
NAME OFINS. CO.
NAME OFCARDHOLDERYES
YES
EMPLOYEE GROUP BENEFITS PLAN OR RETIRED EMPLOYEE GROUP BENEFITS PLAN
ON THE DATE OF THE SICKNESS OR INJURY, INDICATE BELOW IF YOU (OR YOUR SPOUSE) WERE COVERED FOR OUT OF PROVINCE MEDICAL EXPENSES:
CREDIT CARD COVERAGE (IE: GOLD OR OTHER)
ANY OTHER COVERAGE (IE: UNION, PENSIONER, PRIVATE OR OTHER POLICY OR OTHER SOURCES OF RECOVERY) UNDER WHICH YOU ARE ENTITLED TO BENEFITS
FULL TIMEEMPLOYMENT
SELFEMPLOYED
PART TIMEEMPLOYMENT
ADDRESS -NO./STREET/SUITE NO.
POSTAL CODE
POSTAL CODE
PROVINCE
ADDRESS -NO./STREET/SUITE NO.
PROVINCE
STUDENT RETIRED UNEMPLOYED OTHER
TEL. ( )
( )TEL.
YES NO
D
D M Y D M Y D M Y
M Y
D M Y D M Y
PAGE 2
2a
AMOUNTCLAIMED/REFUNDEDHAVE YOU SUBMITTED THIS CLAIM TO YOUR GOVERNMENT HEALTH INSURANCE PLAN? NO YES
AMOUNTCLAIMED/REFUNDEDHAVE YOU SUBMITTED THIS CLAIM TO ANY OTHER PLAN? NO YES
NAME AND ADDRESSOF COMPANYOTHER SOURCES
CREDIT CARD NO.(FIRST 6 DIGITS)
CLA
IMS
INFO
RM
ATI
ON
CLA
IM F
OR
MS
AU
THO
RIZ
ATIO
N &
REL
EAS
ES
Sub
mit
all c
laim
s to
:
AIR
MIL
ES®
AS
SU
RA
NC
E-V
OYA
GE
TRA
VEL
INS
UR
AN
CE
AIR
MIL
ESm
d
c/o
PO
TTR
UFF
&S
MIT
Hc/
o P
OTT
RU
FF &
SM
ITH
TRA
VEL
INS
UR
AN
CE
CO
UR
TIER
S d
’AS
SU
RA
NC
EB
RO
KER
S IN
C.
VO
YAG
E IN
C.
8001
Wes
ton
Rd.
83,
rue
Turg
eon
Sui
te 3
00B
urea
u 30
0W
oodb
ridge
, O
ntar
ioS
te-T
hérè
se,
Qué
bec
L4L
9C8
J7E
3H7
Tele
phon
e: 1
-866
-298
-658
1Te
leph
one:
1-8
66-2
98-6
581
Fax:
905
-856
-153
9Fa
x: 4
50-4
34-5
543
AIR
MIL
ES
®
Trav
el I
nsur
ance