e-Member Services 
 
Summertime Blue Travel Insurance 

Health, Dental and Disability Claim Forms

 

You can access our claim forms online. Click on the link related to the form you need. The form will open in a new browser window. You will then be able to print it (health claims form can be completed online).

Extended Health Care

Extended Health Care Benefits Claim Form

This form is used for health care benefits such as medical or paramedical expenses, drugs or vision care.

Complete this form online, save it, print and sign it, and mail it to us along with your original receipts. 

Important: claims must be submitted no later than 12 months after expenses are incurred.

Dental Care

Dental Care Claim Form

This form is used for dental claims. In most cases, your dentist will be able to submit claims automatically through a system called EDI (electronic data interchange).

If your dentist has EDI, you'll just need to provide your policy and ID numbers. Your dentist will electronically submit your claim to us. We'll mail you or your dentist a reimbursement cheque for any eligible expenses.

If your dentist does not have EDI, please submit the completed and signed dental claim form provided to you by your dentist.

Initial Disability Claim

Claimant's Guide - Disability Insurance

This guide provides information to help you file a claim for disability benefits and/or waiver of premiums. It also includes the forms to be completed to submit your initial claim. The Guide also answers to frequently asked questions (FAQ).

Important: your claim must be submitted to the Insurer within 90 days of the onset of disability.

Overhead Expenses Claim Form - Business Expenses Report

This form is required if you file a claim for Overhead Expenses benefit. You must also provide all supporting documents for each of your expenses.

Your overhead expenses claim being related to a sick leave, you must complete the claim forms for Disability benefits. You will find all of those forms in the Claimant's Guide - Disability Insurance. If your claim is related to Overhead Expenses benefit only, you don't need to provide a proof of income.

Please note that supporting documents may be requested regularly during your sick leave since change in expenses may occur during a disability period.

Information on the creditor and on the loan - Mortgage Plan

This form is required if you file a claim for Mortgage Plan; you must also provide proofs of the last payments made to the creditor.

Your Mortgage Plan claim being related to a leave of absence, you must complete the claim forms for Disability benefits. You will find all of those forms in the  Claimant's Guide - Disability Insurance. If your claim is related to Mortgage Plan benefit only, you don't need to provide a proof of income. 

In case of variable interest, some changes may have occurred in the payments to the creditor. Please note that supporting documentation may be requested regularly during your disability period.

Please be advised that the direct deposit option is not authorized in the case of claims related to a mortgage loan or any other type of loan.

Forms to be completed during a period of disability

Authorization(s)

This authorization allows the insurer to obtain information that is normally valid for 90 days following the date of the signature on the authorization form.
For this reason, it may be required again during the disability. 

Return to Work Notice

This form is required to confirm the date of return to work and to reinstate the automatic benefit increase option on coverage that would have been suspended during the work stoppage. A medical certificate specifying the date of return must be attached to this form.

Accident Statement

This form may be required if the description of the accident given in the Claimant’s Statement form and included in the initial claim is considered incomplete.

Business Expenses Report

This report is necessary when a claim is filed under the Overhead Expenses benefit.
Expense reports and supporting documents are regularly requested during a period of disability. Generally, this information is required every three months as we must ensure that current expenses are equal to the insured amount. 

Employer's Statement

If the insured person has more than one employer, this form may be used to provide them with a copy to be completed. It may also be used if after an attempted return to work, the insured person is disabled again. In this case, the employer must complete the form once again.

Attending Physician's Statement - Additional Report

If the disability has been extended, this form must be completed by your attending physician or specialist. Updated clinical notes must be attached as well as the last medical reports in order to avoid any delays in the processing of your claim. 

Request for payment by direct deposit

If this method of payment was not chosen on the initial claim, it is possible to request it at any time as long as the insurance file is active. Simply complete this form and attach a VOID cheque. Please note that this method of payment is not available if you file a loan or mortgage claim as payments are made directly to your creditor.


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