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

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A separate claim must be filed for the loss when a family member or travelling companion is insured under a different policy number.

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 (Insured)

*Title

*Gender

*First name

*Last name

*Date of Birth

Address in Canada

*Street Address

Street Address line 2

*City

*Province

*Postal Code

*Telephone number
	including area codes

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

Address in Home Country

*Street Address

Street Address line 2

City

Province/State

*Country

ZIP

Telephone number
	including area codes

Fax number
	including area codes

Language
	Main language/dialect spoken if other than English

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

*Title

*Gender

*First name

*Last name

Relationship to Insured

*Date of Birth

Patient's Mailing address (if different from name Insured)

Street Address

City

Province/State

Country

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

*Date of Arrival in Canada

*Expected Departure Date

Diagnosis, and description of symptoms of sickness or injury

*Diagnosis

Expenses

Number of expenses

Type of expense

Name of Service Provider

Date of Service

Currency

Amount Billed

Amount You Paid

Type of expense

Name of Service Provider

Date of Service

Currency

Amount Billed

Amount You Paid

Type of expense

Name of Service Provider

Date of Service

Currency

Amount Billed

Amount You Paid

Type of expense

Name of Service Provider

Date of Service

Currency

Amount Billed

Amount You Paid

Type of expense

Name of Service Provider

Date of Service

Currency

Amount Billed

Amount You Paid

Physician Information

Usual family Physician in your home country

Full name

Telephone number
	including area codes

Street Address

City

Province/State

Country

ZIP

Usual family Physician in Canada

Full name

Telephone number
	including area codes

Street Address

City

Province

Postal Code

Additional Information

Additional information

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