Would you like to inform us about a claim ?
Who is the insured concern by this claim ?
Last Name
First Name
Date of birth
Policy(ies) or certificate(s)
Indicate de type of claim
Death
Date of death
Disability
First date of disability
Primary disabling condition
Accident
When did the accident occur
Indemnity requested
Fracture
Transport charges
Hospitalization
Loss of use of a member or sense
Dental costs
Critical illness
DIagnosis
To whom do we have to send the forms to complete ?
Last Name
First Name
Address
Telephone number (home)
() -
Telephone number (work)
() -
Email address
Relationship
How do you want to receive the forms to complete?
By mail
At the address mentionned before
At another address
Address
By fax
Fax number
() -
Email address
At the address mentionned before
At another address
Email address
Other
No, I will download the forms from your internet site
An agent will contact you as soon as possible to be sure that you downloaded the appropriate forms.
Additionnal information / Remarks