Claimant's preliminary report

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Claimant's preliminary report

General information

Policy No.

Additional policy No(s).

First name

Last name

Email address

Date of birth

Telephone (Home) -

Telephone (Work) - Ext.

Telephone (Cell phone) -

Address of the claimant

Number

Street

Suite or apt.

City

Province

Postal code

Do you have any other disability or medical insurance? Yes No

Name of insurer

Policy No.

Dependant

Is the claim for a dependant? Yes No

First name

Last name

Age

Relationship

Occupation

Are you self-employed? Yes No

Employer's name

Employer's address

Number

Street

Suite or apt.

City

Province

Postal code

Your Occupation

NET earned annual income ($)

Describe your usual duties

Were you working before you became disabled? Yes No

What were you doing?

Treatment

When did you first receive medical treatment?

Where?

Physician

First name

Last name

Since

Physician's address

Number

Street

Suite or apt.

City

Province

Postal code

Other physicians (Please add other doctors information if applicable and click "Add")

First name

Last name

Physician's address

Number

Street

Suite or apt.

City

Province

Postal code

Other physicians

Have you been hospitalized? Yes No

Please add hospitalization information if applicable and click "Add"

Please give dates of confinement

Admitted

Discharged

Hospital

Hospital

Hospital address

Number

Street

Suite or apt.

City

Province

Postal code

Hospitalizations

Condition

Describe the sickness or injury

What are your physical complaints?

If this is a sickness, when did it first begin?

If this is an accident, when and where did it happen?

IMPORTANT: If Motor Vehicle Accident, please attach the Police Report

Place of the accident

How did the accident happen?

Have you had this condition in the past? Yes No

When?

Physician's first name

Last name

Disability

Did the condition described above cause you to lose any time from work? Yes No

First day not worked

Returned part time

Returned full time

What duties are/were you unable to do?

If you are self-employed, is business still operating? Yes No

What duties are you involved in?

If you are unemployed, retired or housewife, what period of disability are you claiming?

Total disability

From

To

Partial disability

From

To

Additional information

If there is any additional information you would like to include, please do so here. Maximum 500 characters

Supporting documents

Please attach any document supporting your claim (Police report, hospital statement, etc.) You must provide us with a clear and legible scanned copy, in .jpg, .png or .pdf format. The total size of the files submitted should not surpass 10 MB.

I CERTIFY that the above information is current, correct and complete and I ACKNOWLEDGE that filling out and submitting this form constitute a "representation" on my part.

I UNDERSTAND the Attending Physician’s Report & Authorization are necessary to complete my claim.