Notify us of a Claim

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Policy and Trip Information

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

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:

REIMBURSEMENT PREFERRED METHOD

Direct Bank Deposit Check

Mailing address:*

Bank Country:*

ABA(branch) 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

+ More Info.

1. Medical Certificate

+ More Info.

1. Death Certificate

+ More Info.

2. Booking Invoice

+ More Info.

3. Proof of Payment

+ More Info.

4. Airline Ticket

+ More Info.

5. Proof of Cancellation

+ More Info.

6. Refund Statement

+ More Info.

1. Medical Certificate

+ More Info.

2. Death Certificate

+ More Info.

3. Booking Invoice

+ More Info.

4. Proof of Payment

+ More Info.

5. Airline Ticket

+ More Info.

6. Proof of Cancellation

+ More Info.

7. Refund Statement

+ More Info.

1. Supporting Documents

+ More Info.

1. Medical Certificate

+ More Info.

1. Medical Certificate

+ More Info.

1. Death Certificate

+ More Info.

2. Airline Ticket

+ More Info.

3. Booking Invoice

+ More Info.

4. Proof of Payment - Original

+ More Info.

5. New Boarding Passes

+ More Info.

6. Proof of Payment - Interruption

+ More Info.

1. Medical Certificate

+ More Info.

2. Death Certificate

+ More Info.

3. Airline Ticket

+ More Info.

4. Booking Invoice

+ More Info.

5. Proof of Payment - Original

+ More Info.

6. New Boarding Passes

+ More Info.

7. Proof of Payment - Interruption

+ More Info.

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

+ More Info.

2. Damaged Luggage Repair Receipt

+ More Info.

3. Property Irregularity Report

+ More Info.

4. Proof of Settlement

+ More Info.

1. Baggage Contents List

+ More Info.

2. Damaged Luggage Repair Receipt

+ More Info.

3. Custody Report

+ More Info.

1. Receipts

+ More Info.

2. Baggage Claim Report

+ More Info.

3. Proof of Delivery

+ More Info.

1. Receipts

+ More Info.

2. Flight delay report

+ More Info.

1. Invoice

+ More Info.

2. Account copy

+ More Info.

3. Police Report

+ More Info.

4. Receipts

+ More Info.

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
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Attach Bills/Documents: *

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

Items Claimed

No	Invoice Description	Purchase Date	Amount Paid	Refund Obtained	Total Amount Claimed	Currency
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CLAIM DETAILS

No	Description	Invoice Date	Amount	Currency
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{{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: 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.

Incident Date:*

Please describe what happened: *

INFORMATION ON OTHER ACTIVE INSURANCE

Do you have other health coverage?*

Yes No

No	Name of Insurance Company	Policy number
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1. I assign to Global Excel Management Inc. any amounts obtainable from other sources for covered losses under this policy. I also direct these sources to forward payment to Global Excel Management Inc. for my claims submitted by Global Excel Management Inc. with regard to these losses and to exchange information that facilitates this process.

I Agree

2. I warrant that neither I, nor any insured person, have any additional coverage through any other insurer (other than that listed above).

I Agree

3. I understand that my insurance shall be void if, whether before or after the loss, any person has concealed or misrepresented any fact or circumstance concerning this claim.

I Agree

4. I authorize any hospital, physician, or medical facility to send my medical information to Global Excel Management Inc., authorized representatives of the Insurer. I further consent to the disclosure of this information by Global Excel Management Inc. to other sources as may be required to obtain benefits from other sources.

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.

Do you have any other travel insurance?

Credit card insurance: *

Yes No

Card Issuer Name: *

Enter your credit card number:*

First 6 Digits

Last 4 Digits

XX XXXX

Other Insurance:*

Yes No

Name of insurance company: *

Policy Number: *

I Agree

2. I warrant that neither I, nor any insured person, have any additional coverage through any other insurer (other than that listed above).

I Agree

3. I understand that my insurance shall be void if, whether before or after the loss, any person has concealed or misrepresented any fact or circumstance concerning this claim.

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.

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Claim Information

{{litIncedentdate}} *

Admitted in Hospital?*

Yes No

{{litClaimdetails}} * Maximum of 1000 characters allowed.

Medical Provider Name:

Medical Provider Phone:

ext:

Country:*

State / Province:*

City:

Postal/Zip Code:

Address:

Phone Number:

Back Next

Verify your request

Attach Bills/Documents:

This section can be used to submit any bills or document(s) that are required by Global Excel Management to properly process your claim. You may consult your policy wording for further details.

Please note the following:

1. 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.

2. Along with the submission of any self-paid bills you will need to provide proof that the expenses has been paid to the provider. Examples of proof of payments: cash register receipt, credit card statement or cheque.

Files	File Size

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Any non-standard tests must be pre-approved by Global Excel Management Inc.; what is meant by non-standard testing is anything other than blood work, x-rays, urine analysis and electrocardiograms.

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{{littravellingremaining}} Contact Us

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{{nonmedicalcontinuation}} Contact Us

I have read the above and understand the terms and conditions.

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Policy and Trip Information

Policyholder Information

Claimant Information

Policyholder Information Policyholder Information

Claimant Information

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

Items Claimed

CLAIM DETAILS

Additional Information

INFORMATION ON OTHER ACTIVE INSURANCE

Do you have any other travel insurance?

Claim Information

{{litLocationofclaim}}

Verify your request

Attach Bills/Documents:

Policyholder Information

Policyholder Information