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* Indicates a required field

Select your insurance type: *

Select your category type: *

Select your card type: *

Select type of Claim: *

Is the policy holder the subject of the claim?

Is the policy holder the subject of the claim? *

Yes No

Was this a result of an accident?

Was this a result of an accident? *

Yes No

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

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?

Is the patient over 15 years of age? *

Yes No

Select one:

Select one: *

Trip Cancellation

If the event happened before you departed on your trip.

Trip Interruption

If the event happened during your trip, or if your flight was delayed.

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.)

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?

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?

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?

Was the deceased person covered under this insurance policy? *

Yes No

Do you have the medical certificate of the deceased person?

Do you have the medical certificate of the deceased person? *

Yes No

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

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?

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?

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?

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

Yes No

Attach Bills/Documents: *

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

What is the reason for your claim?

What is the reason for your claim? *

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

Do you have a Global Excel claim number?

Do you have a Global Excel claim number? *

Yes No

Global Excel claim number: *

{{litareyoucurrentlytravelling}}*

Select your insurance type: *

{{litName}}*

What is the name of your insurance product? *

{{litcertificateno}} *

{{litcertificatenumber}}*

First 6 Digits

Please include a copy of the 1st page of your Account Statement showing your name, card type, the last four digits of the card number with your claim submission in order to allow Global Excel Management to validate your coverage. Should this be missing from your submission you will be contacted directly by Global Excel Management to confirm your full credit card information.

XX XXXX

Last 4 Digits

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:

Specify: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

Policyholder Information

First Name: *

Last Name: *

Date of Birth: *

Title:

Email Address: *

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

{{litcertificatenumber}}*

First 6 Digits

Last 4 Digits

XX XXXX

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Specify: *

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Provincial Health Card Number:

Other Insured Person(s)

Please list other insured person(s) required to claim

No	First Name *	Last Name *	DOB *	*
{{objItem.valNumber}}				Specify:
Add Insured

All fields are required to add an insured person to the claim

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

{{litUpdatedTripCanRDHeader}} List of accepted file types are pdf, tiff, png, jpeg, jpg, gif, bmp, doc, docx, rtf, txt, odt.
Please ensure that any documents uploaded are not password protected. If they are, please remove the password before uploading. This will help reduce delays in processing your claim.

We require that you send us the following requirements in order to process your claim. You can upload these documents to your request using the upload function below. List of accepted file types are pdf, tiff, png, jpeg, jpg, gif, bmp, doc, docx, rtf, txt, odt.
Please ensure that any documents uploaded are not password protected. If they are, please remove the password before uploading. This will help reduce delays in processing your claim.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

A copy of your Credit Card Statement showing the purchase on your credit card or through the redemption of reward points associated with the Account and the first page showing the name and address of cardholder, the card type and the first 6 and last 4 digits of the Credit Card Number. A screenshot of the banking App transactions and/or the online Account Activity Page are not acceptable.

2. Proof of Event

Click on Icon to Upload Files

+ More Info.

Please submit documentation which support the cause of your trip cancellation. This could be a copy of a subpoena for court/jury duty, a letter from your employer, a report from your airline/cruise, etc.

2. Medical Certificate

Click on Icon to Upload Files

+ More Info.

If the cancellation is a result of sickness or injury, please include the medical certificate fully completed by the treating physician. The physician who fills out the medical certificate must be the same one who treated the sick or injured person on the date of the incident that caused the cancellation. If the cancellation is a result of an ongoing health condition (of yourself, spouse, or dependent child), we may request that you provide your family physician's clinical notes at a later date. However if you have these documents available, we recommend you include them with your request now.

2. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are cancelling your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

3. Booking Invoice

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+ More Info.

Attach a copy of your original booking invoice for all travel arrangements

4. Proof of Payment

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+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for each item claimed on the expense list. Please refer to the table below to list your expenses.

5. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

6. Proof of Cancellation

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+ More Info.

Proof of cancellation for each item claimed.

7. Refund Statement

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+ More Info.

If you have received a refund from your travel agent or your travel supplier, please provide a copy of this statement or refund.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Proof of Event

Click on Icon to Upload Files

+ More Info.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

1. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are cancelling your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

2. Booking Invoice

Click on Icon to Upload Files

+ More Info.

Attach a copy of your original booking invoice for all travel arrangements

3. Proof of Payment

Click on Icon to Upload Files

+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for each item claimed on the expense list. Please refer to the table below to list your expenses.

4. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

5. Proof of Cancellation

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+ More Info.

Proof of cancellation for each item claimed.

6. Refund Statement

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+ More Info.

If you have received a refund from your travel agent or your travel supplier, please provide a copy of this statement or refund.

7. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Medical Certificate

Click on Icon to Upload Files

+ More Info.

If the cancellation is a result of the death of an insured person (yourself, spouse or dependent child), please include the medical certificate fully completed by the treating physician. The physician who fills out the medical certificate must be the same one who treated the deceased on the date of the incident that caused the cancellation. Please note we may request that you provide your family physician's clinical notes at a later date. However if you have these documents available, we recommend you include them with your request now.

3. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are cancelling your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

4. Booking Invoice

Click on Icon to Upload Files

+ More Info.

Attach a copy of your original booking invoice for all travel arrangements

5. Proof of Payment

Click on Icon to Upload Files

+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for each item claimed on the expense list. Please refer to the table below to list your expenses.

6. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

7. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Proof of cancellation for each item claimed.

8. Refund Statement

Click on Icon to Upload Files

+ More Info.

If you have received a refund from your travel agent or your travel supplier, please provide a copy of this statement or refund.

9. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

2. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are cancelling your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

3. Booking Invoice

Click on Icon to Upload Files

+ More Info.

Attach a copy of your original booking invoice for all travel arrangements

4. Proof of Payment

Click on Icon to Upload Files

+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for each item claimed on the expense list. Please refer to the table below to list your expenses.

5. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

6. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Proof of cancellation for each item claimed.

7. Refund Statement

Click on Icon to Upload Files

+ More Info.

If you have received a refund from your travel agent or your travel supplier, please provide a copy of this statement or refund.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Proof of Event

Click on Icon to Upload Files

+ More Info.

We required documentation that supports your trip interruption claim. This could be a copy of a subpoena for court/jury duty, a letter from your employer. a report from your airline/cruise, etc.

2. Medical Certificate

Click on Icon to Upload Files

+ More Info.

A medical certificate or letter showing personal attendance by a doctor during the trip, the date and nature of the illness, details of your treatment and the doctor's declaration that it was for medical reasons, for either yourself or other covered persons, that your trip was interrupted. If the interruption is a result of an ongoing health condition (of yourself, spouse or dependent child) we may request that you provide your family physician's clinical notes at a later date. However if you have them on hand already, we recommend you include them with your request now.

2. Medical Certificate

Click on Icon to Upload Files

+ More Info.

2. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are interrupting your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

3. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

4. Booking Invoice

Click on Icon to Upload Files

+ More Info.

Attach a copy of your original booking invoice for all travel arrangements.

5. Proof of Payment - Original

Click on Icon to Upload Files

+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for your original travel arrangements.

6. New Boarding Passes

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+ More Info.

Attach copies of any new flight itinerary or boarding passes.

7. Proof of Payment - Interruption

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+ More Info.

Proof of Payment and receipts for expenses due to the interruption. Please refer to the table below to list your expenses.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

2. Medical Certificate

Click on Icon to Upload Files

+ More Info.

If the interruption is a result of the death of an insured person (yourself, spouse or dependent child), please include the medical certificate fully completed by the treating physician. The physician who fills out the medical certificate must be the same one who treated the deceased on the date of the incident that caused the interruption. Please note we may request that you provide your family physician's clinical notes at a later date. However if you have these documents available, we recommend you include them with your request now.

3. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are interrupting your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

4. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

5. Booking Invoice

Click on Icon to Upload Files

+ More Info.

Attach a copy of your original booking invoice for all travel arrangements.

6. Proof of Payment - Original

Click on Icon to Upload Files

+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for your original travel arrangements.

7. New Boarding Passes

Click on Icon to Upload Files

+ More Info.

Attach copies of any new flight itinerary or boarding passes.

8. Proof of Payment - Interruption

Click on Icon to Upload Files

+ More Info.

Proof of Payment and receipts for expenses due to the interruption. Please refer to the table below to list your expenses.

9. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Proof of Event

Click on Icon to Upload Files

+ More Info.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

1. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are interrupting your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

2. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

3. Booking Invoice

Click on Icon to Upload Files

+ More Info.

Attach a copy of your original booking invoice for all travel arrangements.

4. Proof of Payment - Original

Click on Icon to Upload Files

+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for your original travel arrangements.

5. New Boarding Passes

Click on Icon to Upload Files

+ More Info.

Attach copies of any new flight itinerary or boarding passes.

6. Proof of Payment - Interruption

Click on Icon to Upload Files

+ More Info.

Proof of Payment and receipts for expenses due to the interruption. Please refer to the table below to list your expenses.

7. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

2. Death Certificate

Click on Icon to Upload Files

+ More Info.

In the event that you are interrupting your trip as a result of a death, please provide a copy of the death certificate or obituary of the deceased.

3. Airline Ticket

Click on Icon to Upload Files

+ More Info.

Attach all unused airline ticket(s) and any other travel documents for your original trip.

4. Booking Invoice

Click on Icon to Upload Files

+ More Info.

Attach a copy of your original booking invoice for all travel arrangements.

5. Proof of Payment - Original

Click on Icon to Upload Files

+ More Info.

Submit proof of payment (copy of your credit card statement, copy of cheque, etc.) for your original travel arrangements.

6. New Boarding Passes

Click on Icon to Upload Files

+ More Info.

Attach copies of any new flight itinerary or boarding passes.

7. Proof of Payment - Interruption

Click on Icon to Upload Files

+ More Info.

Proof of Payment and receipts for expenses due to the interruption. Please refer to the table below to list your expenses.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

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. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Baggage Contents List

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+ More Info.

List of the contents of your baggage. Please include original receipts indicating the value, the purchase date, or any proof of ownership such as guarantee, credit card voucher, instruction booklet or picture for each item included in your list of continents. If the original receipt is not available please submit a detailed description of each item which includes the brand, model, size, date of purchase and any other information which may help in determining the replacement cost.

3. Damaged Luggage Repair Receipt

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+ More Info.

If claiming for damaged luggage, please submit an estimate for the repair or receipt for the repair.

4. Property Irregularity Report

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+ More Info.

A Property Irregularity Report when luggage is lost or damaged while in the custody of the airline.

5. Proof of Settlement

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+ More Info.

Proof of settlement with the airline which includes details of the airline's payment or refusal of your claim.

6. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Baggage Contents List

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+ More Info.

2. Damaged Luggage Repair Receipt

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+ More Info.

If claiming for damaged luggage, please submit an estimate for the repair or receipt for the repair.

3. Property Irregularity Report

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+ More Info.

A Property Irregularity Report when luggage is lost or damaged while in the custody of the airline.

4. Proof of Settlement

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+ More Info.

Proof of settlement with the airline which includes details of the airline's payment or refusal of your claim.

5. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Baggage Contents List

Click on Icon to Upload Files

+ More Info.

List of the items which were lost/damaged. Please include original receipts indicating the value, the purchase date, or any proof of ownership such as guarantee, credit card voucher, instruction booklet or picture for each item included in your list of contents. If the original receipt is not available please submit a detailed description of each item which includes the brand, model, size, date of purchase and any other information which may help in determining the replacement cost.

3. Damaged Luggage Repair Receipt

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+ More Info.

If claiming for damaged luggage, please submit an estimate for the repair or receipt for the repair.

4. Custody Report

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+ More Info.

A report by the police and by the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

5. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Baggage Contents List

Click on Icon to Upload Files

+ More Info.

2. Damaged Luggage Repair Receipt

Click on Icon to Upload Files

+ More Info.

If claiming for damaged luggage, please submit an estimate for the repair or receipt for the repair.

3. Custody Report

Click on Icon to Upload Files

+ More Info.

A report by the police and by the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

4. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Receipts

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+ More Info.

Original itemized receipts for expenses actually incurred and description of items purchased.

3. Baggage Claim Report

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+ More Info.

A copy of the baggage claim report issued by the airline.

4. Proof of Delivery

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+ More Info.

Proof of delivery of the baggage.

5. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Receipts

Click on Icon to Upload Files

+ More Info.

Original itemized receipts for expenses actually incurred and description of items purchased.

2. Baggage Claim Report

Click on Icon to Upload Files

+ More Info.

A copy of the baggage claim report issued by the airline.

3. Proof of Delivery

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+ More Info.

Proof of delivery of the baggage.

4. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Receipts

Click on Icon to Upload Files

+ More Info.

Itemized original receipts for actual expenses incurred.

3. Flight delay report

Click on Icon to Upload Files

+ More Info.

Alternate boarding pass or flight delay report from airline

4. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Receipts

Click on Icon to Upload Files

+ More Info.

Itemized original receipts for actual expenses incurred.

2. Flight delay report

Click on Icon to Upload Files

+ More Info.

Alternate boarding pass or flight delay report from airline

3. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Invoice

Click on Icon to Upload Files

+ More Info.

Invoice issued by hotel/motel.

3. Account copy

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+ More Info.

A copy of the account statement in which the full cost of the hotel/motel appears, showing the card as the method of payment.

4. Police Report

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+ More Info.

Police report confirming forced entry and a hotel/motel burglary report.

5. Receipts

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+ More Info.

Receipts for repaired or replaced items.

6. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Invoice

Click on Icon to Upload Files

+ More Info.

Invoice issued by hotel/motel.

2. Account copy

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+ More Info.

A copy of the account statement in which the full cost of the hotel/motel appears, showing the card as the method of payment.

3. Police Report

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+ More Info.

Police report confirming forced entry and a hotel/motel burglary report.

4. Receipts

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+ More Info.

Receipts for repaired or replaced items.

5. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

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.

Select your Card type: *

{{litcertificatenumber}}*

First 6 Digits

XX XXXX

Last 4 Digits

Do you have a Global Excel claim number?

Do you have a Global Excel claim number? *

Yes No

Global Excel claim number: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

First Name: *

Last Name: *

Date of Birth: *

Email Address: *

Home Address: *

Province: *

City: *

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:

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Details of Loss

Loss Type:

Loss Type: *

Damage Theft Lost

Date of Loss: *

Place of Loss:

Country: *

Province/State: *

Province/State:

City: *

Please describe what happened: *

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

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
{{objItem.valNumber}}

PREFERRED METHOD OF REIMBURSEMENT

Direct deposit (For payments less than 10,000 CAD).

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, Institution Number and Account Number

Transit Number: (5 digits) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Other Insurance

Do you have other insurance benefits?

Homeowner / Tenant / Condominium insurance:

Homeowner / Tenant / Condominium insurance: *

Employee, Retiree or Group Plan: *

Homeowner, Tenant, Condominium Insurance: *

Yes No

Homeowner / Tenant / Condominium insurance:

Employee, Retiree or Group Plan:

Do you have other insurance benefits?

Insurance Company: *

Policy No.: *

Credit Card:

Credit Card: *

Yes No

Issuing Bank: *

Card No.:

Card No.: *

First 6 Digits

XX XXXX

Last 4 Digits

Other coverage:

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. List of accepted file types are pdf, tiff, png, jpeg, jpg, gif, bmp, doc, docx, rtf, txt, odt.
Please ensure that any documents uploaded are not password protected. If they are, please remove the password before uploading. This will help reduce delays in processing your claim.

1. Credit Card Statement *

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3. Original Itemized Store Receipt(s)

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Attach a copy of the itemized store receipt for the item purchased.

4. Repair Estimate

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A pre-approval is required before repair. Please attach a copy of the repair estimate.

5. Proof of Loss

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If applicable: A report from the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

6. Personal Insurance

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For claims in excess of $500.00 CAD please attach a photocopy of your personal insurance declaration page.

7. Police Report

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If the item was stolen, please include a copy of the Police report

8. Other Supporting Documents

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Use this button to attach any other document you might have.

2. Original Itemized Store Receipt(s)

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Attach a copy of the itemized store receipt for the item purchased.

3. Repair Estimate

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+ More Info.

A pre-approval is required before repair. Please attach a copy of the repair estimate.

4. Proof of Loss

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+ More Info.

If applicable: A report from the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

5. Personal Insurance

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+ More Info.

For claims in excess of $500.00 CAD please attach a photocopy of your personal insurance declaration page.

6. Police Report

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+ More Info.

If the item was stolen, please include a copy of the Police report

7. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

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..

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.

A claim will be created and we will email you a confirmation with the claim number and additional questions if necessary. Please keep all original receipts and documents pertaining to your claim. Once all documents are received, we will process your claim.

A. 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 *

B. 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 *

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

I Agree *

D. 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 *

E. I consent to Global Excel communicating with me via electronic means regarding my claim at the email address I have provided and understand that this communication will contain personal information.

I Agree *

Select One:

Select One: *

Trip Cancellation

If the event happened before you departed on your trip.

Trip Interruption

If the event happened during your trip.

Flight Delay

If your flight was delayed.

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)

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: *

{{litName}}*

What is the name of your insurance product? *

{{litcertificateno}} *

{{litcertificatenumber}}*

First 6 Digits

XX XXXX

Last 4 Digits

Do you have a Global Excel Claim number?

Do you have a Global Excel Claim number? *

Yes No

Global Excel claim number: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

First Name: *

Last Name: *

Date of Birth: *

Email Address: *

Home Address: *

Province: *

City: *

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:

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Address in Canada: *

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 *	*
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Add Insured

All fields are required to add an insured person to the claim

Details of Loss

Select the cause of the claim:

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

Are you requesting a reimbursement? *

Yes No

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

Please complete all required fields before proceeding.

PREFERRED METHOD OF REIMBURSEMENT

Direct deposit (For payments less than 10,000 CAD).

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) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Other Insurance

Do you have other insurance benefits?

Homeowner / Tenant / Condominium insurance:

Homeowner / Tenant / Condominium insurance: *

Employee, Retiree or Group Plan: *

Homeowner, Tenant, Condominium Insurance: *

Yes No

Homeowner / Tenant / Condominium insurance:

Employee, Retiree or Group Plan:

Do you have other insurance benefits?

Insurance Company: *

Policy No.: *

Credit Card:

Credit Card: *

Yes No

Issuing Bank: *

Card No.:

Card No.: *

First 6 Digits

XX XXXX

Last 4 Digits

Other coverage:

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

1. Credit Card Statement *

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2. Medical Certificate

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If the cancellation is the result of a sickness or injury, please have the medical certificate fully completed by the treating physician. The physician who fills out the medical certificate must be the same one who treated the sick or injured person on the date of the incident that caused the cancellation. If the cancellation is a result of an ongoing health condition (of yourself, spouse, or dependent child), we may request that you provide your family physician's clinical notes at a later date. However, if you have these documents available, we recommend you include them with your request now.

2. Medical Certificate

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If the interruption is the result of a sickness or injury, provide a letter or other document showing personal attendance by a doctor during the trip, the date and nature of the illness, details of the treatment and the doctor’s declaration that your trip was interrupted for medical reasons, for either yourself or other covered individuals.

3. Death Certificate

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If the cancellation or interruption is the result of a death, please attach a copy of the death certificate of the deceased person.

4. Booking Invoice

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Attach a copy of all sales invoices and receipts as proof of payment for your covered trip showing date(s), amount(s) paid, travel supplier fees and penalties, and the method of payment for your insurance. This is required for all the deposits and final payments you made to your travel supplier.

6. Travel Documents

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Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

7. Proof of Cancellation

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Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

8. Proof of refund

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Provide any proof that you requested a refund from your travel agent, tour operator, common carrier, hotel or any other organization to whom you made a prepayment prior to your trip, for unused tickets, vouchers, confirmation notices etc., and that such a refund was denied; or provide proof of any travel refunds received (e.g., credit card statement, explanation of benefits showing amounts received, etc.).

9. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Medical Certificate

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+ More Info.

1. Medical Certificate

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+ More Info.

2. Death Certificate

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+ More Info.

If the cancellation or interruption is the result of a death, please attach a copy of the death certificate of the deceased person.

3. Booking Invoice

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+ More Info.

5. Travel Documents

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+ More Info.

Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

6. Proof of Cancellation

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+ More Info.

Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

7. Proof of refund

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+ More Info.

8. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

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+ More Info.

2. Medical Certificate

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+ More Info.

2. Medical Certificate

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+ More Info.

3. Death Certificate

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+ More Info.

If the cancellation or interruption is the result of a death, please attach a copy of the death certificate of the deceased person.

4. Booking Invoice

Click on Icon to Upload Files

+ More Info.

6. Travel Documents

Click on Icon to Upload Files

+ More Info.

Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

7. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

8. Proof of refund

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+ More Info.

9. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Medical Certificate

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+ More Info.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

2. Death Certificate

Click on Icon to Upload Files

+ More Info.

If the cancellation or interruption is the result of a death, please attach a copy of the death certificate of the deceased person.

3. Booking Invoice

Click on Icon to Upload Files

+ More Info.

5. Travel Documents

Click on Icon to Upload Files

+ More Info.

Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

6. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

7. Proof of refund

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+ More Info.

8. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Medical Certificate

Click on Icon to Upload Files

+ More Info.

2. Medical Certificate

Click on Icon to Upload Files

+ More Info.

3. Booking Invoice

Click on Icon to Upload Files

+ More Info.

5. Travel Documents

Click on Icon to Upload Files

+ More Info.

Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

6. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

7. Proof of refund

Click on Icon to Upload Files

+ More Info.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

1. Medical Certificate

Click on Icon to Upload Files

+ More Info.

2. Booking Invoice

Click on Icon to Upload Files

+ More Info.

4. Travel Documents

Click on Icon to Upload Files

+ More Info.

Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

5. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

6. Proof of refund

Click on Icon to Upload Files

+ More Info.

7. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

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+ More Info.

2. Proof Of Event

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+ More Info.

If the cancellation or interruption is the result of non-medical reasons, please provide documentation to support your claim. This could be a copy of a subpoena for court/jury duty, a letter from your employer, a report from your airline/cruise, a letter from the common carrier, etc.

3. Booking Invoice

Click on Icon to Upload Files

+ More Info.

5. Travel Documents

Click on Icon to Upload Files

+ More Info.

Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

6. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

7. Proof of refund

Click on Icon to Upload Files

+ More Info.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Proof Of Event

Click on Icon to Upload Files

+ More Info.

2. Booking Invoice

Click on Icon to Upload Files

+ More Info.

4. Travel Documents

Click on Icon to Upload Files

+ More Info.

Attach a copy of all unused travel documents (e.g., tickets/e-tickets, cruise booklets, travel vouchers, etc.), as well as the terms and conditions of booking, if applicable.

5. Proof of Cancellation

Click on Icon to Upload Files

+ More Info.

Attach a copy of the cancellation invoice issued by the travel supplier(s) that confirms the penalties and/or cancellation fees applicable to the cancellation of your trip (if applicable).

6. Proof of refund

Click on Icon to Upload Files

+ More Info.

7. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

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.

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.

I Agree *

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

I Agree *

D. 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 *

Card Type is Required

This field is required.

The Global Excel claim number is required.

Provide your Policy/Certificate number is required

Cause of the Claim is Required

Was the deceased person covered under this insurance policy is required

Trip dates From is required.

Trip dates To is required.

Date of Claim Cause is Required

Additional Information is required.

Select your Card type: *

{{litcertificatenumber}}*

First 6 Digits

XX XXXX

Last 4 Digits

{{litcertificateno}} *

Do you have a Global Excel Claim number?

Do you have a Global Excel Claim number? *

Yes No

Global Excel claim number: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

First Name: *

Last Name: *

Date of Birth: *

Email Address: *

Home Address: *

Province: *

City: *

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:

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Details of Loss

Cause of Loss:

Cause of Loss: *

Accident involving another vehicle Collision/Damage Theft

Date of Loss: *

Place of Loss:

Country: *

Province/State: *

Province/State:

City: *

Please describe what happened: *

Was the Policy Holder 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):

Country: *

Province/State: *

Province/State:

City: *

Postal Code: *

Other Vehicle Owner Insurance:

Address (Number, Street):

Country: *

Province/State: *

Province/State:

City: *

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?

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?

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

Yes No

Claim Amount:

Currency:

Benefits are payable to:

Benefits are payable to: *

Rental Agency Other

PREFERRED METHOD OF REIMBURSEMENT

Direct deposit (For payments less than 10,000 CAD).

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) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Other Insurance

Automobile Insurance:

Automobile Insurance: *

Yes No

Insurance Company: *

Policy No.: *

Other Coverage:

Other Coverage: *

Yes No

Insurance Company: *

Policy No.: *

REQUIRED DOCUMENTATION

1. Credit Card Statement *

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3. Rental Agency's Sales Receipt

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+ More Info.

Attach a copy of your sales draft showing that the rental vehicle was paid in full with your credit card.

4. Vehicle Rental Agreement

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The rental agreement is the contract you must sign before you get the keys to your rental vehicle. Attach the original opened and closed vehicle rental agreement.

5. Accident Loss / Damage Report

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Attach a copy of the car rental company’s Accident Loss/Damage Report Form.

6. Repair Estimate

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Attach a copy of the final itemized repair bill or, if not available, a copy of the estimate .

7. Proof of Payment

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Attach receipts for any repairs, which you may have already paid, if applicable, and/or a copy of your credit card statement or pre-billing statement if any repair charges were billed to your account.

8. Police Report

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Attach a copy of the Police Report (required for damages estimated over $1,000).

9. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

2. Rental Agency's Sales Receipt

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+ More Info.

Attach a copy of your sales draft showing that the rental vehicle was paid in full with your credit card.

3. Vehicle Rental Agreement

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+ More Info.

The rental agreement is the contract you must sign before you get the keys to your rental vehicle. Attach the original opened and closed vehicle rental agreement.

4. Accident Loss / Damage Report

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+ More Info.

Attach a copy of the car rental company’s Accident Loss/Damage Report Form.

5. Repair Estimate

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+ More Info.

Attach a copy of the final itemized repair bill or, if not available, a copy of the estimate .

6. Proof of Payment

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+ More Info.

7. Police Report

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+ More Info.

Attach a copy of the Police Report (required for damages estimated over $1,000).

8. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

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.

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.

I Agree *

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

I Agree *

D. 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 *

Select your Card type: *

{{litcertificatenumber}}*

First 6 Digits

XX XXXX

Last 4 Digits

Do you have a Global Excel Claim number?

Do you have a Global Excel Claim number? *

Yes No

Global Excel claim number: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

First Name: *

Last Name: *

Date of Birth: *

Email Address: *

Home Address: *

Province: *

City: *

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:

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Details of Loss

Loss Type:

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)?

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?

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

Direct deposit (For payments less than 10,000 CAD).

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) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Required documentation

1. Credit Card Statement *

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+ More Info.

3. Receipts

Click on Icon to Upload Files

+ More Info.

Attach a copy of the itemized store receipt for the item purchased.

4. Manufacturer's Warranty

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+ More Info.

Attach a copy of the original Manufacturer’s Warranty valid in Canada.

5. Repair Estimate

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A pre-approval is required before repair. Please include a copy of the repair estimate.

6. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

2. Receipts

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+ More Info.

Attach a copy of the itemized store receipt for the item purchased.

3. Manufacturer's Warranty

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+ More Info.

Attach a copy of the original Manufacturer’s Warranty valid in Canada.

4. Repair Estimate

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+ More Info.

A pre-approval is required before repair. Please include a copy of the repair estimate.

5. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

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.

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.

I Agree *

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

I Agree *

D. 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 *

Loss type is required

Loss Occurred Date is Required

Description of Loss is required

Description of Item(s) is required

Provide further details is required

Manufacturer is required

Model Number is required

Serial Number is required

Purchase date is required

Name of the vendor where item was purchased is required

Purchase currency is required

Purchase Price is required

Was the item(s) given as gift(s) is required

Name of the Recipient is required

Address of the Recipient is required

Have you made a previous Purchase Security or Extended warranty claim on this account is required

Previous claim date is required

Select your insurance type: *

{{litName}}*

What is the name of your insurance product? *

{{litcertificateno}} *

{{litcertificatenumber}}*

First 6 Digits

XX XXXX

Last 4 Digits

Do you have a Global Excel Claim number?

Do you have a Global Excel Claim number? *

Yes No

Global Excel claim number: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

First Name: *

Last Name: *

Date of Birth: *

Email Address: *

Home Address: *

Province: *

City: *

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:

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Address in Canada: *

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 *	*
{{objItem.valNumber}}
Add Insured

All fields are required to add an insured person to the claim

Claim Information

Claiming for:

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?

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

Are you requesting a reimbursement? *

Yes No

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

Please complete all required fields before proceeding.

PREFERRED METHOD OF REIMBURSEMENT

Direct deposit (For payments less than 10,000 CAD).

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) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Other Insurance

Do you have other insurance benefits?

Homeowner / Tenant / Condominium insurance:

Homeowner / Tenant / Condominium insurance: *

Employee, Retiree or Group Plan: *

Homeowner, Tenant, Condominium Insurance: *

Yes No

Homeowner / Tenant / Condominium insurance:

Employee, Retiree or Group Plan:

Do you have other insurance benefits?

Insurance Company: *

Policy No.: *

Credit Card:

Credit Card: *

Yes No

Issuing Bank: *

Card No.:

Card No.: *

First 6 Digits

XX XXXX

Last 4 Digits

Other coverage:

Any other coverage: *

Other coverage: *

Yes No

Insurance Company: *

Policy No.: *

REQUIRED DOCUMENTATION

1. Credit Card Statement *

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+ More Info.

2. Account Statement

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+ More Info.

A copy of your account statement showing that the ticket was purchased with your credit card.

3. Tickets

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A copy of the tickets and/or the itinerary for the common carrier.

4. Baggage Claim Ticket

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A copy of the baggage claim stubs issued by the airline or common carrier.

5. Original Itemized Store Receipt(s)

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+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

6. Common Carrier Report

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For Baggage Delay: A statement from the common carrier confirming the delay of checked baggage including the reason and the duration of the delay, and a copy of the delivery receipt for your checked baggage.

For Baggage Loss: A copy of the Property Irregularity Report when baggage is lost or damaged while in custody of the airline.

7. Proof of Settlement

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Proof of settlement for any claim submitted to the airline, supplier or any other insurance company.

If your baggage is not returned to you, a statement of liability accepted by the common carrier, if applicable.

A copy of a statement from your homeowner’s or tenant’s insurance carrier indicating the reimbursement received for any items permanently lost with your baggage.

8. Baggage Contents List

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If applicable: List of the lost or damaged items. Please include original receipts indicating the value and purchase date, or any proof of ownership such as a guarantee, a credit card voucher, an instruction booklet or a picture for each item included in your list of contents. If the original receipt is not available, please submit a detailed description of each item, including the brand, model, size, date of purchase and any other information which may help in determining the replacement cost.

9. Proof of Loss

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If applicable: A report from the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

10. Police Report

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+ More Info.

If the item was stolen, please include a copy of the Police report.

11. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Account Statement

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+ More Info.

A copy of your account statement showing that the ticket was purchased with your credit card.

2. Tickets

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+ More Info.

A copy of the tickets and/or the itinerary for the common carrier.

3. Baggage Claim Ticket

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+ More Info.

A copy of the baggage claim stubs issued by the airline or common carrier.

2. Original Itemized Store Receipt(s)

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+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

5. Common Carrier Report

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+ More Info.

For Baggage Loss: A copy of the Property Irregularity Report when baggage is lost or damaged while in custody of the airline.

6. Proof of Settlement

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+ More Info.

Proof of settlement for any claim submitted to the airline, supplier or any other insurance company.

If your baggage is not returned to you, a statement of liability accepted by the common carrier, if applicable.

A copy of a statement from your homeowner’s or tenant’s insurance carrier indicating the reimbursement received for any items permanently lost with your baggage.

7. Baggage Contents List

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+ More Info.

4. Proof of Loss

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+ More Info.

If applicable: A report from the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

6. Police Report

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+ More Info.

If the item was stolen, please include a copy of the Police report.

6. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

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+ More Info.

2. Tickets

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+ More Info.

A copy of the tickets and/or the itinerary for the common carrier.

3. Common Carrier Report

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+ More Info.

A statement from the common carrier confirming the delay of checked baggage including the reason and the duration of the delay, and a copy of the delivery receipt for your checked baggage.

4. Itemized Receipts

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+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

5. Proof of Settlement

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+ More Info.

Proof of settlement for any claim submitted to the airline, supplier or any other insurance company.

6. Proof of delivery

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Proof of delivery of checked baggage.

7. Other Supporting Documents

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+ More Info.

Use this button to attach any other document you might have.

1. Tickets

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+ More Info.

A copy of the tickets and/or the itinerary for the common carrier.

2. Common Carrier Report

Click on Icon to Upload Files

+ More Info.

A statement from the common carrier confirming the delay of checked baggage including the reason and the duration of the delay, and a copy of the delivery receipt for your checked baggage.

3. Itemized Receipts

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+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

4. Proof of Settlement

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+ More Info.

Proof of settlement for any claim submitted to the airline, supplier or any other insurance company.

5. Proof of delivery

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+ More Info.

Proof of delivery of checked baggage.

6. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

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+ More Info.

2. Tickets

Click on Icon to Upload Files

+ More Info.

A copy of the tickets and/or the itinerary for the common carrier.

3. Baggage Content List

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+ More Info.

4. Itemized Receipts

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+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

5. Common Carrier Irregularity/Loss Report

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+ More Info.

A copy of the Property Irregularity Report when baggage is lost or damaged while in custody of the airline.

If applicable: A report from the hotel manager, tour guide or transportation authorities in whose custody the insured property was at the time of loss.

6. Proof of Settlement

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+ More Info.

Proof of settlement for any claim submitted to the airline, supplier or any other insurance company.
If your baggage is not returned to you, a statement of liability accepted by the common carrier, if applicable.

A copy of a statement from your homeowner’s or tenant’s insurance carrier indicating the reimbursement received for any items permanently lost with your baggage.

7. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Tickets

Click on Icon to Upload Files

+ More Info.

A copy of the tickets and/or the itinerary for the common carrier.

2. Baggage Content List

Click on Icon to Upload Files

+ More Info.

3. Itemized Receipts

Click on Icon to Upload Files

+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

4. Common Carrier Irregularity/Loss Report

Click on Icon to Upload Files

+ More Info.

5. Proof of Settlement

Click on Icon to Upload Files

+ More Info.

6. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Tickets

Click on Icon to Upload Files

+ More Info.

A copy of the tickets and/or the itinerary for the common carrier.

3. Baggage Content List

Click on Icon to Upload Files

+ More Info.

4. Itemized Receipts

Click on Icon to Upload Files

+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

5. Common Carrier Irregularity/Loss Report

Click on Icon to Upload Files

+ More Info.

6. Police Report

Click on Icon to Upload Files

+ More Info.

If the item was stolen, please include a copy of the Police report.

7. Proof of Settlement

Click on Icon to Upload Files

+ More Info.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Tickets

Click on Icon to Upload Files

+ More Info.

A copy of the tickets and/or the itinerary for the common carrier.

2. Baggage Content List

Click on Icon to Upload Files

+ More Info.

3. Itemized Receipts

Click on Icon to Upload Files

+ More Info.

Attach itemized receipts for actual expenses incurred for essential clothing and toiletries.

4. Common Carrier Irregularity/Loss Report

Click on Icon to Upload Files

+ More Info.

5. Police Report

Click on Icon to Upload Files

+ More Info.

If the item was stolen, please include a copy of the Police report.

6. Proof of Settlement

Click on Icon to Upload Files

+ More Info.

7. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

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.

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.

I Agree *

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

I Agree *

D. 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 *

Are you currently travelling? *

Are you seeking or planning to seek medical attention? *

If you are currently travelling, seeking treatment, or planning to seek treatment please contact us at +1-519-988-0934, for toll-free number+1-888-332-3044

Please select your province of residence: *

Please print, complete, and sign the provincial form. Once completed, upload a photocopy along with your other required documents.

Select your insurance type: *

{{litName}}*

What is the name of your insurance product? *

{{litcertificateno}} *

{{litcertificatenumber}}*

First 6 Digits

XX XXXX

Last 4 Digits

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

Policyholder Information

First Name: *

Last Name: *

Date of Birth: *

Title:

Email Address: *

Address in Canada: *

Province: *

City: *

Postal Code: *

Phone Number: *

Is the claimant the policyholder? *

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Specify: *

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

First Name: *

Last Name: *

Date of Birth: *

Email Address: *

Home Address: *

Province: *

City: *

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:

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Preferred Method of Contact: *

Do you authorize us to communicate with you regarding your claim using this e-mail address with the understanding that these communications may contain personal information?
I agree*

Other Insurance?

Do you have any other insurance?

Do you have any other insurance? *

Yes No

Name of insurance company/policy number: *

Have you filed a claim with them?

Have you filed a claim with them? *

Yes No

Attach a copy of the Claim: *

Click on Icon to Upload Files Sorry, this document is required to submit your claim. Please kindly upload the requested document.

{{litUploadNote}} List of accepted file types are doc, pdf, txt, pcx, docx, jpg, jpeg, jpe, jfif, gif, tiff, tif, bmp, png.
Please ensure that any documents uploaded are not password protected. If they are, please remove the password before uploading. This will help reduce delays in processing your claim.

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

PREFERRED METHOD OF REIMBURSEMENT

Direct deposit (For payments less than 10,000 CAD).

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) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Travel Information:

Travel Destination:

Travel Destination: *

Country: *

City: *

Departure Date: *

Return Date: *

Reason for Consult:

Are you claiming for an illness or injury?

Are you claiming for an illness or injury? *

illness injury

illness

Reason for Consult: *

First date of treatment: *

When did first symptoms appear? *

Was there an official diagnosis?

Was there an official diagnosis? *

Yes No

Diagnosis: *

Have you ever experienced this illness before?

Have you ever experienced this illness before? *

Yes No

Last Episode date: *

Have you ever received a consult or treatment for this illness?

Have you ever received a consult or treatment for this illness? *

Yes No

Last Appointment Date: *

Have you been admitted to a hospital before for this condition?

Have you been admitted to a hospital before for this condition? *

Yes No

Admissions dates:

Admissions dates: *

Admit Date: *

Discharge Date: *

Reason for admission: *

Admitting symptoms: *

List names of any medications you were taking prior to visiting the doctor:

injury

Date of Injury: *

Please explain how the injury occurred? *

Where did the injury occur? *

Is there another party who may be responsible for your injury?

Is there another party who may be responsible for your injury? *

Yes No

Do you plan to pursue legal action and have you obtained a legal representative?

Do you plan to pursue legal action and have you obtained a legal representative? *

Yes No

Lawyer Name: *

Phone Number: *

Do you have a family physician?

Do you have a family physician? *

Yes No

Name: *

Phone Number: *

Provincial Health Card Number

Health Card Number: *

Attach a Provincial Form:

Click on Icon to Upload Files Sorry, this document is required to submit your claim. Please kindly upload the requested document.

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

Required Documentation

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Itemized receipts for all bills and invoices

Click on Icon to Upload Files

+ More Info.

A copy of any bills and invoices provided by a medical facility.

3. Proof of Payment

Click on Icon to Upload Files

+ More Info.

A copy of the transaction receipt for the payment of an invoice.

4. Medical Records including complete diagnosis by attending physician.

Click on Icon to Upload Files

+ More Info.

Consult notes, prescription note, discharge report, etc.

5. Proof of Travel

Click on Icon to Upload Files

+ More Info.

Proof of Travel (pref: itinerary, boarding passes) driving: proof of last when in their home province, proof of when at destination and reverse when return home.

6. Police accident report - MVA including report number (If applicable)

Click on Icon to Upload Files

+ More Info.

A copy of the police accident report including the report number if the reason for consult is due to an accident or motor vehicle accident.

7. Pharmacy Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy receipt that includes the prescription name, prescribed quantity and patients name.

8. Pharmacy Transaction Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy transaction receipt for the purchase of the prescription.

9. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Itemized receipts for all bills and invoices

Click on Icon to Upload Files

+ More Info.

A copy of any bills and invoices provided by a medical facility.

2. Proof of Payment

Click on Icon to Upload Files

+ More Info.

A copy of the transaction receipt for the payment of an invoice.

3. Medical Records including complete diagnosis by attending physician.

Click on Icon to Upload Files

+ More Info.

Consult notes, prescription note, discharge report, etc.

4. Proof of Travel

Click on Icon to Upload Files

+ More Info.

Proof of Travel (pref: itinerary, boarding passes) driving: proof of last when in their home province, proof of when at destination and reverse when return home.

5. Police accident report - MVA including report number (If applicable)

Click on Icon to Upload Files

+ More Info.

A copy of the police accident report including the report number if the reason for consult is due to an accident or motor vehicle accident.

6. Pharmacy Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy receipt that includes the prescription name, prescribed quantity and patients name.

7. Pharmacy Transaction Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy transaction receipt for the purchase of the prescription.

8. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

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.

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.

I Agree *

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

I Agree *

D. 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 *

{{litcertificateno}} *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

Policyholder Information

First Name: *

Last Name: *

Date of Birth: *

Title:

Email Address: *

Address in Canada: *

Province: *

City: *

Postal Code: *

Phone Number: *

Is the claimant the policyholder? *

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Specify: *

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Note

Before proceeding with the claim form, please carefully review the documents listed in the 'Required Documents' section on this page to ensure you have them readily available.

First Name: *

Last Name: *

Date of Birth: *

Email Address: *

Home Address: *

Province: *

City: *

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:

Claimant Information

First Name: *

Last Name: *

Date of Birth: *

Email Address:

Relationship:

Address in Canada: *

Province: *

City: *

Postal Code:

Phone Number: *

Preferred Method of Contact: *

Do you authorize us to communicate with you regarding your claim using this e-mail address with the understanding that these communications may contain personal information?
I agree*

Other Insurance?

Do you have any other insurance?

Do you have any other insurance? *

Yes No

Name of insurance company/policy number: *

Have you filed a claim with them?

Have you filed a claim with them? *

Yes No

Attach a copy of the Claim: *

Click on Icon to Upload Files Sorry, this document is required to submit your claim. Please kindly upload the requested document.

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

PREFERRED METHOD OF REIMBURSEMENT

Direct deposit (For payments less than 10,000 CAD).

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) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Travel Information:

Travel Destination:

Travel Destination: *

Country: *

City: *

Departure Date: *

Return Date:

Home Country: *

Date of Arrival to Canada: *

Reason for Consult:

Are you claiming for an illness or injury?

Are you claiming for an illness or injury? *

illness injury

illness

Was this an annual or wellness exam?

Was this an annual or wellness exam? *

Annual Wellness

Reason for Consult: *

First date of treatment: *

When did first symptoms appear? *

Was there an official diagnosis?

Was there an official diagnosis? *

Yes No

Diagnosis: *

Have you ever experienced this illness before?

Have you ever experienced this illness before? *

Yes No

Last Episode date: *

Have you ever received a consult or treatment for this illness?

Have you ever received a consult or treatment for this illness? *

Yes No

Last Appointment Date: *

Have you been admitted to a hospital before for this condition?

Have you been admitted to a hospital before for this condition? *

Yes No

Admissions dates:

Admissions dates: *

Admit Date: *

Discharge Date: *

Reason for admission: *

Admitting symptoms: *

List names of any medications you were taking prior to visiting the doctor:

injury

Date of Injury: *

Please explain how the injury occurred? *

Where did the injury occur? *

Is there another party who may be responsible for your injury?

Is there another party who may be responsible for your injury? *

Yes No

Do you plan to pursue legal action and have you obtained a legal representative?

Do you plan to pursue legal action and have you obtained a legal representative? *

Yes No

Lawyer Name: *

Phone Number: *

Do you have a family physician?

Do you have a family physician? *

Yes No

Name: *

Phone Number: *

Do you have any chronic illness or disease?

Do you have any chronic illness or disease? *

Yes No

No	Name of illness *	Date Last Consulted *	Still Seeking Treatment?
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All fields are mandatory to enter chronic illness or disease is required.

Required Documentation

1. Credit Card Statement *

Click on Icon to Upload Files

+ More Info.

2. Itemized receipts for all bills and invoices

Click on Icon to Upload Files

+ More Info.

A copy of any bills and invoices provided by a medical facility.

3. Proof of Payment

Click on Icon to Upload Files

+ More Info.

A copy of the transaction receipt for the payment of an invoice.

4. Medical Records including complete diagnosis by attending physician.

Click on Icon to Upload Files

+ More Info.

Consult notes, prescription note, discharge report, etc.

5. Proof of Travel

Click on Icon to Upload Files

+ More Info.

Proof of Travel (pref: itinerary, boarding passes) driving: proof of last when in their home province, proof of when at destination and reverse when return home.

6. Police accident report - MVA including report number (If applicable)

Click on Icon to Upload Files

+ More Info.

A copy of the police accident report including the report number if the reason for consult is due to an accident or motor vehicle accident.

7. Pharmacy Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy receipt that includes the prescription name, prescribed quantity and patients name.

8. Pharmacy Transaction Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy transaction receipt for the purchase of the prescription.

9. Proof of Arrival to Canada

Click on Icon to Upload Files

+ More Info.

A copy of your airfare ticket, passport stamp or receipts confirming travel dates and entry into Canada

10. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

1. Itemized receipts for all bills and invoices

Click on Icon to Upload Files

+ More Info.

A copy of any bills and invoices provided by a medical facility.

2. Proof of Payment

Click on Icon to Upload Files

+ More Info.

A copy of the transaction receipt for the payment of an invoice.

3. Medical Records including complete diagnosis by attending physician.

Click on Icon to Upload Files

+ More Info.

Consult notes, prescription note, discharge report, etc.

4. Proof of Travel

Click on Icon to Upload Files

+ More Info.

Proof of Travel (pref: itinerary, boarding passes) driving: proof of last when in their home province, proof of when at destination and reverse when return home.

5. Police accident report - MVA including report number (If applicable)

Click on Icon to Upload Files

+ More Info.

A copy of the police accident report including the report number if the reason for consult is due to an accident or motor vehicle accident.

6. Pharmacy Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy receipt that includes the prescription name, prescribed quantity and patients name.

7. Pharmacy Transaction Receipt

Click on Icon to Upload Files

+ More Info.

A copy of the pharmacy transaction receipt for the purchase of the prescription.

8. Proof of Arrival to Canada

Click on Icon to Upload Files

+ More Info.

A copy of your airfare ticket, passport stamp or receipts confirming travel dates and entry into Canada

9. Other Supporting Documents

Click on Icon to Upload Files

+ More Info.

Use this button to attach any other document you might have.

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.

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.

I Agree *

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

I Agree *

D. 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 *

Client Signature: *

First Name Last Name: *

I Accept *

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.

Sign above

Items Claimed

Are you requesting a reimbursement? *

Yes No

No	Invoice Description	Purchase Date	Amount Paid	Refund Obtained	Total Amount Claimed	Currency
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Please complete all required fields before proceeding.

CLAIM DETAILS

No	Description	Invoice Date	Amount	Currency
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{{litName}}*

What is the name of your insurance product? *

{{litcertificateno}} *

Provincial Health Card Number (if applicable): *

Additional Information

Do you have a Global Excel claim number?

Do you have a Global Excel claim number? *

Yes No

Global Excel claim number: *

{{litareyoucurrentlytravelling}}*

Country of Origin:

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.

What are the trip dates? *

Arrival in Canada:

Planned Departure:

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?

Do you have other health coverage? *

Yes No

No	Name of Insurance Company	Policy number
{{objItem.valNumber}}

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.

PREFERRED METHOD OF REIMBURSEMENT

Direct deposit (For payments less than 10,000 CAD).

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) * Please enter at least 5 characters

Institution Number: (3 digits) * Please enter at least 3 characters

Account Number: (6 to 12 digits) * Account Number should be between 6 to 12 digits

Cheque

Do you have any other travel insurance?

Credit card insurance:

Credit card insurance: *

Yes No

Card Issuer Name: *

Enter your credit card number:

Enter your credit card number: *

First 6 Digits

XX XXXX

Last 4 Digits

Other Insurance:

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 *

4. I consent to Global Excel communicating with me via electronic means regarding my claim at the email address I have provided and understand that this communication will contain personal information.

I Agree *

5. 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 *

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.

I Agree *

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

I Agree *

D. 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.

Claim Information

{{litIncedentdate}} *

Admitted in Hospital?

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:

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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
Click on Icon to Upload Files
{{file.FileName}}	{{file.FileLength}}

List of accepted file types are doc, pdf, txt, pcx, docx, jpg, jpeg, jpe, jfif, gif, tiff, tif, bmp, png.
Please ensure that any documents uploaded are not password protected. If they are, please remove the password before uploading. This will help reduce delays in processing your claim.

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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{{nonmedicalcontinuation}} Contact Us

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

SUBMIT CLAIM

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