Notify us of a Claim

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* Indicates a required field

Select your insurance type: *

Select your category type: *

Select your card type: *

Select type of Claim: *

Select type of Claim:*

Is the policy holder the subject of the claim?*

Yes No

Was this a result of an accident?

Yes No

Was the patient admitted to a hospital for over 24 hours (inpatient) or less (outpatient)?

Inpatient Outpatient

Is the patient over 15 years of age?

Yes No

Select one:*

Trip Cancellation Trip Interruption

Have you contacted your travel provider to collect a refund and have documentation that confirms the amount of refund granted? (This could be in the form of cash or credit.)

Yes No

Please be sure to attach this documentation to your claim. As per the terms and conditions of your policy, you may be entitled to a reimbursement of the non-refundable portion of your prepaid travel arrangements. If you have been, or will be, refunded in the form of a credit from your travel provider, we will be unable to provide reimbursement under this policy.

As per the terms and conditions of your policy, you may be entitled to a reimbursement of the non- refundable portion of your prepaid travel arrangements. If credits exist from your travel provider, we will be unable to provide reimbursement under this policy.

Are you cancelling your trip due to a medical reason or a death?*

Yes No

At the time of the trip cancellation, what was the cause of the cancellation itself?

Due to a death Medical Reason

Was the deceased person covered under this insurance policy?

Yes No

Do you have the medical certificate of the deceased person?

Yes No

Do you have the Global Excel Medical Certificate completed?

Yes No

Are you interrupting your trip due to a medical reason or a death?

Yes No

At the time of the trip interruption, what was the cause of the interruption itself?

Due to a death Medical Reason

Was the deceased person covered under this insurance policy?

Yes No

Was this due to a medical condition of an insured under this policy that was also travelling?

Yes No

Do you have the Global Excel Medical Certificate completed?

Yes No

Attach Bills/Documents:*

Files	File Size
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What is the reason for your baggage claim?*

Lost or Stolen Baggage (With Airline)
Lost or Stolen Baggage (Other)
Baggage Delay
Flight Delay

Select your insurance type: *

Policyholder Information

First Name:*

Last Name:*

Date of Birth:*

Policy Number:

Member ID:

Network Identifier:

Phone Number:*

Email Address:*

Is the claimant the policyholder? *

Claimant Information

First Name:*

Last Name:*

Date of Birth:*

Relationship:*

Policyholder Information

Policyholder Information

First Name:*

Last Name:*

Date of Birth:*

Title:

Email Address:*

Address in Canada:*

Province:*

City:*

Zip / Postal Code:

Phone Number:*

{{litcertificatenumber}}*

First 6 Digits

Last 4 Digits

XX XXXX

Is the claimant the policyholder? *

Claimant Information

First Name:*

Last Name:*

Date of Birth:*

Email Address:

Relationship:*

Address in Canada:*

Province:*

City:*

Zip / Postal Code:

Phone Number:*

Provincial Health Card Number:

Program Coordinator Information

If you are a Program Coordinator completing this claim on behalf of the organization or cardholder, please complete the following fields:

Program Coordinator Name:

Date of Birth:

Email Address:

Business Address:

Province:

City:

Postal Code:

Phone Number:

PREFERRED METHOD OF REIMBURSEMENT

Direct Bank Deposit Check

Mailing address:*

Bank Country:*

ABA(branch) / Transit Number:*

Account Number:*

Type:*

Email to transfer funds:*

Transit Number:*

Institution number:*

Account number:*

REQUIRED DOCUMENTATION

We require a completed medical certificate. Please print and have it completed. You can also email it to yourself for later printing.

Print Email

Enter your email address:*

Send

We require that you send us the following requirements in order to process you claim. You can upload these documents to your request using the upload function below.

1. Supporting Documents

1. Medical Certificate

1. Death Certificate

2. Booking Invoice

3. Proof of Payment

4. Airline Ticket

5. Proof of Cancellation

6. Refund Statement

1. Medical Certificate

2. Death Certificate

3. Booking Invoice

4. Proof of Payment

5. Airline Ticket

6. Proof of Cancellation

7. Refund Statement

1. Supporting Documents

1. Medical Certificate

1. Death Certificate

2. Airline Ticket

3. Booking Invoice

4. Proof of Payment - Original

5. New Boarding Passes

6. Proof of Payment - Interruption

1. Medical Certificate

2. Death Certificate

3. Airline Ticket

4. Booking Invoice

5. Proof of Payment - Original

6. New Boarding Passes

7. Proof of Payment - Interruption

1. Invoices

Take and upload clear pictures of the invoices for medical, dental or pharmacy services purchased.

2. Receipts

Take and upload clear pictures of the receipts for payment of associated invoices. Credit card or bank statements will not be accepted.

3. Complete Form Accurately.

1. Baggage Contents List

2. Damaged Luggage Repair Receipt

3. Property Irregularity Report

4. Proof of Settlement

1. Baggage Contents List

2. Damaged Luggage Repair Receipt

3. Custody Report

1. Receipts

2. Baggage Claim Report

3. Proof of Delivery

1. Receipts

2. Flight delay report

1. Invoice

2. Account copy

3. Police Report

4. Receipts

Note that it is extremely important to submit all required documents when returning your request to us. If any documents are missing, it could cause delays.

When using the upload function, we recommend that you take clear digital pictures of the documents you wish to upload.

Attach Bills/Documents:

Files	File Size
{{file.FileName}}	{{file.FileLength}}

Attach Bills/Documents: *

Files	File Size
{{file.FileName}}	{{file.FileLength}}

Select your Card type:*

{{litcertificatenumber}}*

First 6 Digits

Last 4 Digits

XX XXXX

Do you have a Global Excel claim number? *

Yes No

Global Excel claim number: *

Cardholder Information

First Name:*

Last Name:*

Date of Birth:*

Email Address:*

Home Address:*

Province:*

City: *

Zip/Postal Code: *

Phone Number:*

Program Coordinator Information

If you are a Program Coordinator completing this claim on behalf of the organization or cardholder, please complete the following fields:

Program Coordinator Name:

Date of Birth:

Email Address:

Business Address:

Province:

City:

Postal Code:

Phone Number:

Details of Loss

Loss Type:*

Damage Theft Lost

Date of Loss:*

Place of Loss:

Country:*

Province/State:*

City:*

Please describe what happened: *

Have you made a previous Purchase Security or Extended Warranty Claim on this account?*

Yes No

Previous Claim Date:*

Previous Claim Number:*

Incurred Expenses

No	Item Description	Purchase Date	Manufacturer	Model/Serial #	Purchase Price
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PREFERRED METHOD OF REIMBURSEMENT

Interac e-transfer (For payments less than 10,000 CAD).

By providing your email address, you will receive an email notification once your claim is settled and you may directly deposit your reimbursement to the online banking platform you choose.

Email:*

Direct deposit (CAD only).

By providing your banking information, your claim payments will be deposited directly to your account and you will get an email notification when when your claim is settled.

Transit Number: (5 digits)*

Institution Number: (3 digits)*

Account Number: (12 digits)*

Cheque

Other Insurance

Do you have other insurance benefits?

Homeowner / Tenant / Condominium insurance: *

Employee, Retiree or Group Plan: *

Homeowner, Tenant, Condominium Insurance:*

Yes No

Insurance Company: *

Policy No.: *

Credit Card: *

Yes No

Issuing Bank:*

Card No.:*

First 6 Digits

Last 4 Digits

XX XXXX

Any other coverage: *

Other coverage: *

Yes No

Insurance Company:*

Policy No.:*

REQUIRED DOCUMENTATION

We require that you send us the following documents in order to process your claim. You can attach these documents to your request using the upload function below.

1. Account Statement

2. Original Itemized Store Receipt(s)

3. Repair Estimate

4. Proof of Loss

5. Personal Insurance

6. Police Report

Note that it is very important to submit all required documents when returning your request to us. If any documents are missing, it could cause delays.

When using the upload function, we recommend that you take clear digital pictures of the documents..

Attach Bills/Documents:

Files	File Size
{{file.FileName}}	{{file.FileLength}}

Authorization

I Agree *

Authorization

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I Agree *

Please keep all original documentation for your records after submitting your claim. Under exceptional circumstances, we may require that you send us original documents or a signed claim form.

Select One:*

Trip Cancellation Trip Interruption Flight Delay

Have you contacted your travel provider to collect a refund and have you received documentation that confirms the amount of refund granted? (This could be in the form of cash or credit)*

Yes No

Select your insurance type: *

Select your Card type:*

{{litcertificatenumber}}*

First 6 Digits

Last 4 Digits

XX XXXX

Provide your Policy/Certificate number: *

Do you have a Global Excel Claim number? *

Yes No

Global Excel claim number: *

Cardholder Information

First Name:*

Last Name:*

Date of Birth:*

Email Address:*

Home Address:*

Province:*

City: *

Zip/Postal Code: *

Phone Number:*

Program Coordinator Information

If you are a Program Coordinator completing this claim on behalf of the organization or cardholder, please complete the following fields:

Program Coordinator Name:

Date of Birth:

Email Address:

Business Address:

Province:

City:

Postal Code:

Phone Number:

Other Insured Person(s)

Please list other insured person(s) required to claim

No	First Name *	Last Name *	DOB *	Relationship to the Cardholder *
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Add Insured

Details of Loss

Select the cause of the claim:*

Due to Death Medical Reason Non- Medical Reason

Trip Dates:*

From:

To:

If you are submitting a claim for expenses outside of the province where you attend school you will need to include proof of those travel dates. Examples: airline tickets or gas receipts.

Date of Claim Cause:*

Please describe what happened:*

Incurred Expenses

No	Invoice Description	Purchase Date	Amount Paid	Refund Obtained	Total Amount Claimed	Currency
{{objItem.valNumber}}

PREFERRED METHOD OF REIMBURSEMENT

Interac e-transfer (For payments less than 10,000 CAD).

By providing your email address, you will receive an email notification once your claim is settled and you may directly deposit your reimbursement to the online banking platform you choose.

Email:*

Direct deposit (CAD only).

By providing your banking information, your claim payments will be deposited directly to your account and you will get an email notification when when your claim is settled.

Transit Number: (5 digits)*

Institution Number: (3 digits)*

Account Number: (12 digits)*

Cheque

Other Insurance

Do you have other insurance benefits?

Homeowner / Tenant / Condominium insurance: *

Employee, Retiree or Group Plan: *

Homeowner, Tenant, Condominium Insurance:*

Yes No

Insurance Company: *

Policy No.: *

Credit Card: *

Yes No

Issuing Bank:*

Card No.:*

First 6 Digits

Last 4 Digits

XX XXXX

Any other coverage: *

Other coverage: *

Yes No

Insurance Company:*

Policy No.:*

REQUIRED DOCUMENTATION

We require a completed medical certificate. Please print and have it completed. You can also email it to yourself for later printing.

Print Email

Enter your email address:*

Send

We require that you send us the following documents in order to process your claim. You can attach these documents to your request using the upload function below.

1. Medical Certificate

2. Death Certificate

3. Booking Invoice

4. Account Statement

5. Travel Documents

6. Proof of Cancellation

7. Proof of refund

1. Medical Certificate

2. Death Certificate

3. Booking Invoice

4. Account Statement

5. Travel Documents

6. Proof of Cancellation

7. Proof of refund

1. Medical Certificate

2. Booking Invoice

3. Account Statement

4. Travel Documents

5. Proof of Cancellation

6. Proof of refund

1. Supporting Documents

2. Booking Invoice

3. Account Statement

4. Travel Documents

5. Proof of Cancellation

6. Proof of refund

Note that it is extremely important to submit all required documents when returning your request to us. If any documents are missing, it could cause delays.

When using the upload function, we recommend that you take clear digital pictures of the documents you wish to upload.

Attach Bills/Documents:

Files	File Size
{{file.FileName}}	{{file.FileLength}}

Authorization

I Agree *

Authorization

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I Agree *

Please keep all original documentation for your records after submitting your claim. Under exceptional circumstances, we may require that you send us original documents or a signed claim form.

Select your Card type:*

{{litcertificatenumber}}*

First 6 Digits

Last 4 Digits

XX XXXX

Do you have a Global Excel Claim number?*

Yes No

Global Excel claim number: *

Cardholder Information

First Name:*

Last Name:*

Date of Birth:*

Email Address:*

Home Address:*

Province:*

City: *

Zip/Postal Code: *

Phone Number:*

Program Coordinator Information

If you are a Program Coordinator completing this claim on behalf of the organization or cardholder, please complete the following fields:

Program Coordinator Name:

Date of Birth:

Email Address:

Business Address:

Province:

City:

Postal Code:

Phone Number:

Details of Loss

Cause of Loss: *

Accident involving another vehicle Collision/Damage Theft

Date of Loss:*

Place of Loss:

Country:*

Province/State:*

City:*

Please describe what happened:*

Was the Cardholder the driver at the time of Loss?*

Yes No

Name of driver (at time of loss)

First Name:*

Last Name:*

Relationship to the Cardholder:*

Specify:*

Vehicle Make:*

Vehicle Model:*

Vehicle Year:*

Police Report Number:

Other Vehicle Information

Vehicle Owner:

Home address (Number, Street):

City: *

Province/State:*

Postal Code: *

Other Vehicle Owner Insurance:

Address (Number, Street):

City:*

Province/State: *

Postal Code: *

Insurance Policy Number:

Claim No.:

Vehicle License plate:

Vehicle Make / Model / Year

Province / State of Registration:

If the other vehicle Owner was not the driver, provide the name and address of the driver:

Claim Summary

Was the full cost of the rental charged to your credit card?*

Yes No

Did you have a rental agreement prior or following this rental?*

Yes No

Claim Amount:

Currency:

Benefits are payable to:*

Cardholder Rental Agency Other

PREFERRED METHOD OF REIMBURSEMENT

Interac e-transfer (For payments less than 10,000 CAD).

By providing your email address, you will receive an email notification once your claim is settled and you may directly deposit your reimbursement to the online banking platform you choose.

Email:*

Direct deposit (CAD only).

By providing your banking information, your claim payments will be deposited directly to your account and you will get an email notification when when your claim is settled.

Transit Number: (5 digits)*

Institution Number: (3 digits)*

Account Number: (12 digits)*

Cheque

Other Insurance

Automobile Insurance:*

Yes No

Insurance Company:*

Policy No.:*

Other Coverage:*

Yes No

Insurance Company:*

Policy No.: *

REQUIRED DOCUMENTATION

We require that you send us the following documents in order to process your claim. You can attach these documents to your request using the upload function below.

1. Account Statement

2. Rental Agency's Sales Receipt

3. Vehicle Rental Agreement

4. Accident Loss / Damage Report

5. Repair Estimate

6. Proof of Payment

7. Police Report

Note that it is extremely important to submit all required documents when returning your request to us. If any documents are missing, it could cause delays.

When using the upload function, we recommend that you take clear digital pictures of the documents you wish to upload.

Attach Bills/Documents:

Files	File Size
{{file.FileName}}	{{file.FileLength}}

Authorization

I Agree *

Authorization

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I Agree *

Please keep all original documentation for your records after submitting your claim. Under exceptional circumstances, we may require that you send us original documents or a signed claim form.

Select your Card type:*

{{litcertificatenumber}}*

First 6 Digits

Last 4 Digits

XX XXXX

Do you have a Global Excel Claim number?*

Yes No

Global Excel claim number: *

Cardholder Information

First Name:*

Last Name:*

Date of Birth:*

Email Address:*

Home Address:*

Province:*

City: *

Zip/Postal Code: *

Phone Number:*

Program Coordinator Information

If you are a Program Coordinator completing this claim on behalf of the organization or cardholder, please complete the following fields:

Program Coordinator Name:

Date of Birth:

Email Address:

Business Address:

Province:

City:

Postal Code:

Phone Number:

Details of Loss

Loss Type: *

Mechanical breakdown Failure Other

Provide further details:*

Date Loss occurred:*

Description of the Loss:*

Item Information

Description of the item:*

Manufacturer:*

Model number:

Serial number:

Purchase date:*

Name of Vendor where the Item was purchased:*

Purchase price: *

Currency:*

Was the item(s) given as a gift(s)? *

Yes No

Name of recipient:*

Address of recipient:*

Have you made a previous Purchase Security or Extended Warranty claim on this account? *

Yes No

Previous claim date:*

Previous claim number:*

PREFERRED METHOD OF REIMBURSEMENT

Interac e-transfer (For payments less than 10,000 CAD).

By providing your email address, you will receive an email notification once your claim is settled and you may directly deposit your reimbursement to the online banking platform you choose.

Email:*

Direct deposit (CAD only).

By providing your banking information, your claim payments will be deposited directly to your account and you will get an email notification when when your claim is settled.

Transit Number: (5 digits)*

Institution Number: (3 digits)*

Account Number: (12 digits)*

Cheque

Required documentation

We require that you send us the following documents in order to process your claim. You can attach these documents to your request using the upload function below.

1. Account Statement

2. Receipts

3. Manufacturer's Warranty

4. Repair Estimate

Note that it is extremely important to submit all required documents when returning your request to us. If any documents are missing, it could cause delays.

When using the upload function, we recommend that you take clear digital pictures of the documents you wish to upload.

Attach Bills/Documents:

Files	File Size
{{file.FileName}}	{{file.FileLength}}

Authorization

I Agree *

Authorization

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I Agree *

Please keep all original documentation for your records after submitting your claim. Under exceptional circumstances, we may require that you send us original documents or a signed claim form.

Select your insurance type:*

Select your Card type:*

{{litcertificatenumber}}*

First 6 Digits

Last 4 Digits

XX XXXX

Provide your Policy/Certificate number:*

Do you have a Global Excel Claim number?*

Yes No

Global Excel claim number:*

Cardholder Information

First Name:*

Last Name:*

Date of Birth:*

Email Address:*

Home Address:*

Province:*

City: *

Zip/Postal Code: *

Phone Number:*

Program Coordinator Information

If you are a Program Coordinator completing this claim on behalf of the organization or cardholder, please complete the following fields:

Program Coordinator Name:

Date of Birth:

Email Address:

Business Address:

Province:

City:

Postal Code:

Phone Number:

Other Insured Person(s)

Please list other insured person(s) required to claim

No	First Name *	Last Name *	DOB *	Relationship to the Cardholder *
{{objItem.valNumber}}
Add Insured

Claim Information

Claiming for:*

Delay Loss Damage Theft

Date of Loss:*

Place where the incident occurred:

City:*

Country:*

Did you file a report with the police or other authority?*

Yes No

Flight departing from:

Departure Date:

Airline:

Flight No.:

Final Destination:

Arrival Date:

Airline:

Flight No.:

Airline that lost the baggage:

Number of checked baggage:

Number of lost baggage:

Date you received the Baggage:

Local time you received the baggage:

Number of hours delayed:

Incurred Expenses

No	Invoice Description	Purchase Date	Amount Paid	Refund Obtained	Total Amount Claimed	Currency
{{objItem.valNumber}}

PREFERRED METHOD OF REIMBURSEMENT

Interac e-transfer (For payments less than 10,000 CAD).

By providing your email address, you will receive an email notification once your claim is settled and you may directly deposit your reimbursement to the online banking platform you choose.

Email:*

Direct deposit (CAD only).

By providing your banking information, your claim payments will be deposited directly to your account and you will get an email notification when when your claim is settled.

Transit Number: (5 digits)*

Institution Number: (3 digits)*

Account Number: (12 digits)*

Cheque

Other Insurance

Do you have other insurance benefits?

Homeowner / Tenant / Condominium insurance: *

Employee, Retiree or Group Plan: *

Homeowner, Tenant, Condominium Insurance:*

Yes No

Insurance Company: *

Policy No.: *

Credit Card: *

Yes No

Issuing Bank:*

Card No.:*

First 6 Digits

Last 4 Digits

XX XXXX

Any other coverage: *

Other coverage: *

Yes No

Insurance Company:*

Policy No.:*

REQUIRED DOCUMENTATION

We require that you send us the following documents in order to process your claim. You can attach these documents to your request using the upload function below.

1. Account Statement

2. Tickets

3. Baggage Claim Ticket

4. Itemized Receipts

5. Common Carrier Report

6. Proof of Settlement

7. Baggage Contents List

8. Proof of Loss

9. Police Report

Note that it is very important to submit all required documents when returning your request to us. If any documents are missing, it could cause delays.

When using the upload function, we recommend that you take clear digital pictures of the documents.

Attach Bills/Documents:

Files	File Size
{{file.FileName}}	{{file.FileLength}}

Authorization

I Agree *

Authorization

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I declare that all statements made in this claim form are accurate, true and complete. I understand that making false, misleading or incomplete statements may cause not only the claim to be denied, but insurance coverage to be rescinded by the Insurer. The undersigned agrees to refund the amount of any payments that should not have been made.
By signing below, you agree that we may collect, use and disclose your Information as described in the Privacy Agreement including for, but not limited to, the purposes of identifying you, providing ongoing service, processing your claims, understanding your financial needs, protecting us both from fraud and error and complying with legal and regulatory requirements. For further details about this Privacy Agreement and our privacy practices, visit www.gem.com/privacy or contact us for a copy.
I authorize any other insurance carrier to release and exchange with GEM Life Insurance Company ("GEM Life'') and/or GEM Home & Auto Insurance Company (“GEM H&A”) and its administrator Global Excel Management Inc. (“Global Excel “) or its representatives’ benefits payment information relating to this claim.
The information provided with respect to this claim will be used by GEM H&A and its administrator Global Excel or their representatives to investigate any losses, assess any entitlement to benefits and to administer this claim, and as otherwise indicated in the privacy terms available at gem.com/privacy, or included with your Certificate/Policy of Insurance. We will investigate and administer this claim by consulting the insurer’s existing files and by exchanging information with the undersigned and third parties, such as law enforcement, fire and emergency services departments, parties involved with any subrogation action, and other independent sources. This may, in some cases, include the transfer of your data outside the territory of Canada.
I authorize Global Excel (including its representatives or affiliates) to disclose to GEM Life and/or GEM Home & Auto any information relating to this claim that it may have in its possession including information it obtains from third parties. I am aware that any authorization I provide to Global Excel to obtain information about this claim from any third party is also an authorization for GEM Life and/or GEM Home & Auto to obtain copies of the information.
I also authorize the Insurer, its reinsurers and its respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. This consent shall be valid during the continuation of such claim.
I agree to provide all necessary assistance to secure the rights and remedies to subrogation of the claim against third parties who may be responsible for the claim.
I understand that if I am a dependent under this insurance coverage, the named Insured Person will have access to information related to this claim in connection with the administration of this plan.
I agree that a photocopy or facsimile of this authorization shall be valid as the original and that this authorization shall be considered valid for the duration of this claim, but not to exceed two years from the date it is signed. I understand information about me may be reviewed in the event that this plan is audited.

I Agree *

Please keep all original documentation for your records after submitting your claim. Under exceptional circumstances, we may require that you send us original documents or a signed claim form.

Items Claimed

No	Invoice Description	Purchase Date	Amount Paid	Refund Obtained	Total Amount Claimed	Currency
{{objItem.valNumber}}

CLAIM DETAILS

No	Description	Invoice Date	Amount	Currency
{{objItem.valNumber}}

{{litName}}*

What is the name of your insurance product?*

{{litcertificateno}} *

Additional Information

Do you have a Global Excel claim number?*

Yes No

Global Excel claim number: *

{{litareyoucurrentlytravelling}}*

What are the trip dates? *

From:

Policyholder Information

Claimant Information

Policyholder Information Policyholder Information

Claimant Information

Program Coordinator Information

REQUIRED DOCUMENTATION

1. Supporting Documents

1. Medical Certificate

1. Death Certificate

2. Booking Invoice

3. Proof of Payment

4. Airline Ticket

5. Proof of Cancellation

6. Refund Statement

1. Medical Certificate

2. Death Certificate

3. Booking Invoice

4. Proof of Payment

5. Airline Ticket

6. Proof of Cancellation

7. Refund Statement

1. Supporting Documents

1. Medical Certificate

1. Medical Certificate

1. Death Certificate

2. Airline Ticket

3. Booking Invoice

4. Proof of Payment - Original

5. New Boarding Passes

6. Proof of Payment - Interruption

1. Medical Certificate

2. Death Certificate

3. Airline Ticket

4. Booking Invoice

5. Proof of Payment - Original

6. New Boarding Passes

7. Proof of Payment - Interruption

1. Invoices

2. Receipts

3. Complete Form Accurately.

1. Baggage Contents List

2. Damaged Luggage Repair Receipt

3. Property Irregularity Report

4. Proof of Settlement

1. Baggage Contents List

2. Damaged Luggage Repair Receipt

3. Custody Report

1. Receipts

2. Baggage Claim Report

3. Proof of Delivery

1. Receipts

2. Flight delay report

1. Invoice

2. Account copy

3. Police Report

4. Receipts

Cardholder Information

Program Coordinator Information

Details of Loss

Incurred Expenses

Other Insurance

REQUIRED DOCUMENTATION

1. Account Statement

2. Original Itemized Store Receipt(s)

3. Repair Estimate

4. Proof of Loss

5. Personal Insurance

6. Police Report

Authorization

Authorization

Cardholder Information

Program Coordinator Information

Other Insured Person(s)

Details of Loss

Incurred Expenses

Other Insurance

REQUIRED DOCUMENTATION

1. Medical Certificate

2. Death Certificate

3. Booking Invoice

Policyholder Information

Policyholder Information