TIC Travel Insurance Coordinators Ltd. - How To Make A Claim

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A separate claim must be filed for each person incurring a loss.

Items marked with * are required. Please also complete all relevant information in any non-mandatory fields as it pertains to your claim. Depending on the claim, additional information may be requested.

Personal Information

*Title

*First name

*Last name

*Date of Birth

Insured's complete mailing address

*Street Address

Street Address line 2

*City

*Province/State

*Postal/ZIP Code

Contact Information

*Telephone number
	including area codes

Fax number
	including area codes

Language
	Main language/dialect spoken if other than English

Email Address
	Note: It is important that the security setting of your email account is set properly to avoid our reply e-mails being put into your spam folders

TIC Policy Information

*Policy Number

*Plan

*Purchase Date
	yyyy-mm-dd Date your insurance was purchased

*Agency/Broker
	Name of Insurance agency/broker where you purchased your insurance

Patient information

First name

Last name

Relationship to Insured

Date of Birth

*Health Card number
	include any version codes

Patient's mailing address (if different from insureds)

Street Address

City

Province/State

Postal/ZIP Code

Physician Information

Usual family physician

Full name

Telephone number
	including area codes

Street Address

City

Province/State

Postal/ZIP Code

Other treating physician

Full name

City

Province/State

Postal/ZIP Code

Other Insurance

*Other insurance?
	Do you have any other extended health or out-of-country insurance coverage?

If yes, Policy or Group number

Insurance company

Telephone number
	including area codes

Dates of Travel

*Departure date

*Return date

Diagnosis, and description of symptoms of sickness or injury

*Diagnosis

Expenses

Expense incurred in

Number of expenses

Date
	Date of expense

Type of expense

Cost

Currency

Additional Information

Additional information

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