1. Policy Number: 742845693
2. Policy Holder’s Name: Xyz yzz – as it shows on the government ID
3. Policyholder’s Employer: Xyz Transportation
4. Policyholder’s Address: 123 Flamingo Crescent, Brampton (ON), Canada L6R7K*
5. Policy Holder’s Occupation: Bookkeeper
6. Policyholder’s Union & Local: UFCW Local 1006A or ACFO-ACAF
7. Patients Name: Xyz Yzz (Name of the patient – most likely Life Insured)
8. Patient’s Birthday: 24/10/1988
9. Relationship to the policyholder: Life Insured/patient is the policyholder or can be a family
member. Life Insured may be the policy owner or the life insured may be someone the policy
owner knows such as a family member – the policy owner is usually the payor – the person who
pays for the policy unless the policy owner, life insured and the payor are all three different
people which is also possible..
10. Name of Other Insurance Companies which cover this claim: Example: Canada Life for Group
Disability Insurance
11. List of names and addresses for Doctor’s Consulted:
Doctor’s Name: Xyz Yuu,
Address: 123 hospital drive, Brampton (ON), Canada (L5G2G3),
Dates of treatment: 24/10/2023 (Day, Month, year)
12. If hospitalized:
Hospital: Brampton Civic Hospital – 2100 Bovaird Drive East, Brampton (ON) L6R3J7.
Dates: From 24/10/2023-27/12/ 2023 (Date/Month/Year)
13. Date that symptoms first appeared: 24/10/2023
14. Date of first treatment by the doctor: 25/10/2023
15. Nature of sickness or accident:
If Critical Illness: Heart Attack. If accident: Impalement by an object for example
16. If an accident: How did it happen: Auto Accident – Brake Failure/Malfunction
17. Date of the Accident: 24/10/2023 – In this case, there were no symptoms prior to the accident
so first day symptom appeared will be the same as the day of the accident.
18. Have you ever had symptoms before: Critical illness – No (If there was critical illness, you would
need to mention the date the symptoms first appeared…) For example: first symptoms appeared
on 24/09/2023 (Consider Pre-existing conditions…claim may be denied if first symptoms
appeared within 12 months of the issue date of the policy), Accident: Yes
19. Date Required to give up work: 24/10/2023 (Talk about benefits, waiting period and recurring
benefits)
20. Date Returned to work: 28/12/2023 (In terms of disability benefits if any – consider the
definition of own occupation, regular occupation and any occupation – explain)
21. List of all sickness or injuries for which treatment was required:
Condition: Heart Attack – 24/10/2022 – Prior to the accident --- for example:
Accident: Impalement in an Auto Accident: 24/10/2023
22. Claimant’s signature: Usually policyholder but may be life insured as well if policyholder is the
life insured. The person who is making a claim for the benefits.. Should match the signature on a
government Photo ID
23. Email address: Policyholder’s email
2. Policy Holder’s Name: Xyz yzz – as it shows on the government ID
3. Policyholder’s Employer: Xyz Transportation
4. Policyholder’s Address: 123 Flamingo Crescent, Brampton (ON), Canada L6R7K*
5. Policy Holder’s Occupation: Bookkeeper
6. Policyholder’s Union & Local: UFCW Local 1006A or ACFO-ACAF
7. Patients Name: Xyz Yzz (Name of the patient – most likely Life Insured)
8. Patient’s Birthday: 24/10/1988
9. Relationship to the policyholder: Life Insured/patient is the policyholder or can be a family
member. Life Insured may be the policy owner or the life insured may be someone the policy
owner knows such as a family member – the policy owner is usually the payor – the person who
pays for the policy unless the policy owner, life insured and the payor are all three different
people which is also possible..
10. Name of Other Insurance Companies which cover this claim: Example: Canada Life for Group
Disability Insurance
11. List of names and addresses for Doctor’s Consulted:
Doctor’s Name: Xyz Yuu,
Address: 123 hospital drive, Brampton (ON), Canada (L5G2G3),
Dates of treatment: 24/10/2023 (Day, Month, year)
12. If hospitalized:
Hospital: Brampton Civic Hospital – 2100 Bovaird Drive East, Brampton (ON) L6R3J7.
Dates: From 24/10/2023-27/12/ 2023 (Date/Month/Year)
13. Date that symptoms first appeared: 24/10/2023
14. Date of first treatment by the doctor: 25/10/2023
15. Nature of sickness or accident:
If Critical Illness: Heart Attack. If accident: Impalement by an object for example
16. If an accident: How did it happen: Auto Accident – Brake Failure/Malfunction
17. Date of the Accident: 24/10/2023 – In this case, there were no symptoms prior to the accident
so first day symptom appeared will be the same as the day of the accident.
18. Have you ever had symptoms before: Critical illness – No (If there was critical illness, you would
need to mention the date the symptoms first appeared…) For example: first symptoms appeared
on 24/09/2023 (Consider Pre-existing conditions…claim may be denied if first symptoms
appeared within 12 months of the issue date of the policy), Accident: Yes
19. Date Required to give up work: 24/10/2023 (Talk about benefits, waiting period and recurring
benefits)
20. Date Returned to work: 28/12/2023 (In terms of disability benefits if any – consider the
definition of own occupation, regular occupation and any occupation – explain)
21. List of all sickness or injuries for which treatment was required:
Condition: Heart Attack – 24/10/2022 – Prior to the accident --- for example:
Accident: Impalement in an Auto Accident: 24/10/2023
22. Claimant’s signature: Usually policyholder but may be life insured as well if policyholder is the
life insured. The person who is making a claim for the benefits.. Should match the signature on a
government Photo ID
23. Email address: Policyholder’s email
