CLAIMANT PACKAGE – LIFE INSURANCE
This package contains the form required for you to report a Life Claim. Please submit the completed form as soon as possible to allow timely
assessment and management of the claim. Please include any information you feel we should consider in our assessment of the claim.
When proceeds are payable to a named beneficiary, the Claimant Statement should be completed by the beneficiary,
except in the following situations:
• If any named beneficiary has predeceased the life Insured, proof of death must be provided in the form of a death certificate for the
predeceased beneficiary.
• If a trustee was appointed by the deceased to act on behalf of the beneficiary, the trustee should complete the Claimant Statement.
• If the beneficiary is a minor and the deceased has not appointed a trustee, contact First Canadian to determine who should complete
the Claimant Statement. Legislation regarding payment to minors differs from province to province.
• If the beneficiary is not able to handle their own financial affairs, the Claimant Statement should be completed by their legal
representative. Please submit a notarized copy of the legal appointment (Power of Attorney Document or Court-Appointed Committee)
with the claim documents.
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When proceeds are payable to the Estate, the Claimant Statement should be completed by the Estate’s legal
representative. Please submit one of the following with the claim documents:
• A notarized copy of the will and probate; or
• Certificate of Appointment of Estate Trustee with or without a will; or
• Letter of Administration.
THE FOLLOWING INFORMATION IS REQUIRED BEFORE WE CAN PROCESS YOUR CLAIM:
• Declaration and Authorization for Release of Personal Information – Your permission to obtain information is needed to help
us assess this claim. This authorization ensures the collection and use of information is in accordance with privacy legislation. By signing
this form, you permit First Canadian Insurance Corporation (First Canadian) to exchange information with the Insured’s doctor, the
employer, other insurers and hospitals where the Insured received treatment, subject to privacy legislation.
• Claimant Statement – Asks general information about the Insured and the Claimant and the circumstances surrounding the claim.
• Attending Physician’s Statement – Please have the Insured’s physician complete this form.
• Additional Documents – Please provide these documents:
–– A copy of the Birth and Death Certificate (or Funeral Director’s Statement)
–– If death is accidental, the police report or workplace accident report
• Employer Statement – The Insured’s Employer will complete and submit this report.
The request for documentation is intended to address the most common situations. Depending on the circumstances, we may need to
request additional information or documentation before we can make a claim decision.
First Canadian Group Benefits, 582 King Edward Street, Winnipeg, MB R3H 0P1
1-866-212-5644 • [email protected]
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FC-Life Claimant Pkg-03-16
CLAIMANT STATEMENT – LIFE INSURANCE
Declaration and authorization for release of personal information
Personal information we collect is kept in strict confidence and will be used to assess this claim and to administer the deceased’s
entitlement to benefits under the group plan.
I declare the statements made in this Authorization and in any personal or telephone interview concerning the claim(s) for benefits are
true and complete. I understand all such statements will be considered in determining entitlement to benefits.
I authorize:
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• First Canadian Insurance Corporation (First Canadian), any healthcare provider, plan administrator, any insurance or reinsurance
company, administrators of government benefits or other benefits programs, any person having knowledge of the deceased, other
organizations, or service providers working with First Canadian, to exchange personal information when relevant and necessary for the
purpose of investigating and assessing this claim, administering coverage the deceased may have with First Canadian and administering
the group benefits plan. The parties to whom this information may be disclosed include any third party administrator acting on behalf of
First Canadian.
• First Canadian to disclose personal information about the deceased’s claim(s) to an auditor authorized by the employer, plan sponsor,
or their advisor, or by First Canadian for the purpose of auditing the assessment of claims.
I acknowledge personal information is needed to investigate and assess the deceased’s claim(s), to administer coverage(s) administered
by First Canadian and to administer the group benefits plan. I acknowledge my consent enables First Canadian to process the deceased’s
claim(s) and refusing to consent may result in delay or denial of my claim(s).
This consent may be revoked by me at any time by sending a written instruction to First Canadian.
Except for audit purposes, the authorizations shall remain valid for the duration of the claim for benefits or until otherwise revoked by me.
I confirm a photocopy or electronic copy of this authorization shall be as valid as the original.
I acknowledge more specific information about collection and use of personal information can be found in the Privacy Policy section of
www.firstcanadian.ca or from the administrator of the benefit program.
Signature
Print Name
Relationship to Deceased
Date
Employee Information
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Company Name
Firm/Division #
Employee’s Full Name Certificate #
Home Mailing Address
Apartment/Street
City/Town
Date of Birth (YYYY/MM/DD)
First Canadian Group Benefits, 582 King Edward Street, Winnipeg, MB R3H 0P1
1-866-212-5644 • [email protected]
Province
Sex
q Male
Postal Code
q Female
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FC-Life Claimant Pkg-03-16
CLAIMANT STATEMENT – LIFE INSURANCE (CONTINUED)
Claim Information
Death of:
q Employee
q Dependent
Relationship to Employee
Name of Deceased
Date of Birth (YYYY/MM/DD)
Date of Death (YYYY/MM/DD)Cause of Death
Please attach a copy of the Birth and Death Certificate (or Funeral Director’s Statement) for the Deceased.
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Duration of illness, if applicable:
Years
Months
Was death accidental?
q Yes
Did the deceased ever use any form of tobacco, marijuana, nicotine products or substitutes
(including nicotine patch and gum)?
q Yes q No q Unknown
q No
If MVA, was the deceased the driver?
If Yes, date of accident (YYYY/MM/DD)
Time
q Yes
am/pm
q No
Name and address of investigating police department, if applicable. Be sure to include the police report and/or the workplace
accident report.
Claimant Information
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I am making this application in the capacity of:
q Beneficiary q Executor/Executrix q Trustee q Other: Please specify:
Please submit the appropriate notarized documentation to support your right to claim, as indicated on the cover page.
Claimant Name
Relationship to Deceased
Address
Phone (
)
Date of Birth (YYYY/MM/DD)
Social Insurance Number (Required in the event benefit or interest is deemed taxable)
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Declaration
I certify the information contained in this application is true, correct and complete to the best of my knowledge. I understand all phone
conversations with First Canadian representatives are recorded for quality assurance, training purposes, and dispute resolution.
Claimant Signature
Date
First Canadian Group Benefits, 582 King Edward Street, Winnipeg, MB R3H 0P1
1-866-212-5644 • [email protected]
Page 3 of 3
FC-Life Claimant Pkg-03-16
ATTENDING PHYSICIAN STATEMENT – LIFE INSURANCE
(Sections 1 & 2 to be completed by claimant prior to submitting to Attending Physician)
Employee Information
1
Company Name Firm/Division #
Employee’s Full Name Home Mailing Address
Certificate #
APARTMENT/STREET
CITY/TOWN
PROVINCE
Date of Birth (YYYY/MM/DD)
Sex
q Male
POSTAL CODE
q Female
Claim Information
Name of Claimant
2
Relationship to Employee
I hereby authorize the release of medical and health information in respect to this claim to First Canadian Insurance Corporation (First
Canadian) and/or its insuring partners and authorized advisors for the purpose of assessing my claim and administering the benefits plan.
The parties to whom this information may be disclosed include any third party administrator acting on behalf of First Canadian. This
medical and health information includes, but is not limited to, copies of all consultation reports, clinical notes, test results and hospital
records. This consent can be revoked at any time but without it the claim may not be assessed. The claimant is responsible for any fees
related to the completion of this form.
Claimant’s Signature
Date (YYYY/MM/DD)
Attending Physician Statement (completed by the physician)
Your detailed response will help us process your patients claim more quickly. Your patient or the patient’s estate is responsible for any
charge for completing this form.
Deceased Information
Name of Deceased
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Date of Birth (YYYY/MM/DD)
Date of Death (YYYY/MM/DD)
Place of Death
If hospital or institution, provide name
Cause of Death
Date Symptoms Date of First
First Appeared
Diagnosis
(YYYY/MM/DD)(YYYY/MM/DD)
Immediate Cause
Underlying Cause
Other Significant Conditions
Please provide any additional information about the illness or accident (including any underlying conditions) available to you.
First Canadian Group Benefits, 582 King Edward Street, Winnipeg, MB R3H 0P1
1-866-212-5644 • [email protected]
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FC-Life APS-03-16
ATTENDING PHYSICIAN STATEMENT – LIFE INSURANCE (CONTINUED)
Deceased Information (continued)
Was the deceased advised of the nature of his/her illness?
Death classified as:
q Natural
Was an inquest held?
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q Yes
q Accident
q Yes
q Suicide
q No
q Homicide
If Yes, when? (YYYY/MM/DD)
q Other (specify):
q No
Was an autopsy performed?
q Yes q No
Please provide a copy of the autopsy results.
If Yes, by whom?
When did deceased first become your patient? (YYYY/MM/DD)
Had the patient been treated by any other physician/hospital?
q Yes
q No
If Yes, provide physician and/or hospital names below.
Did the deceased ever use any form of tobacco, marijuana, nicotine products or substitutes (including nicotine patch and gum)?
q Yes q No q Unknown
I hereby declare the answers to the above questions are accurate and complete.
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Physician Signature
Date (YYYY/MM/DD)
Physician Name (please print)
I am:
q Family Doctor
q Specialist
q Specialty
Address
Phone (
)
Fax (
)
Thank you, doctor, for taking the time to complete this form.
First Canadian Group Benefits, 582 King Edward Street, Winnipeg, MB R3H 0P1
1-866-212-5644 • [email protected]
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FC-Life APS-03-16