Claim Form

Policy No.:
Claim No.:
Card Account No.:
CIBC OUT-OF-PROVINCE IMPORTANT: Failure to sign both sides of this form will
TRAVEL MEDICAL INSURANCE result in a delay of the processing of your claim.

Section A - Claimant Information (Please print)

PATIENT’S INFORMATION PRIMARY CARDHOLDER’S INFORMATION
Last First Initial Last First Initial
Li Shiran SL Li Shiran SL
✔ Male
o o Female Date of birth (M/D/Y) Address (number & street) Date of birth (M/D/Y)
07 /_____
_____ 13 /_____1990 1848 Mount Albert Rd. _____
07 /_____ 13 /_____1990
Relationship: ✔o Self o Spouse o Dependent City Province Postal code
o Check if child is full-time student Sharon ON L0G 1V0
Provincial health number 8665 904 887 AB 416 ___________________ Home: ( )
Home: ( ) 274 3390 ___________________

Family physician & all other physicians consulted within the ninety days Diagnosis of illness or injury (while travelling)
prior to the date of departure Dislocation of Shoulder

Country/province where claim occured Date of incident (M/D/Y) ____/____/____

11 30 2020 Currency CAD
Alberta, Canada
Trip date: From (M/D/Y): _____
11 /_____
27 /_____ To (M/D/Y):
2020 _____
12 /_____
01 /_____
2020

Section B – Cardholder’s Preferred Method of Reimbursement

Please visit www.globalexcelservices.com to log in or register to our secure claimant portal and choose your preferred method of reimbursement.
You can also change your method of reimbursement by completing this section.

Please complete this form ✔o Interac e-transfer (For payments less than 10,000 CAD).


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

Email address: _______________________________________________________________________________
steve.works@live.ca

o Direct deposit (CAD only).

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

Transit Number: Institution number: Account Number:

o Cheque

Section C - Other Insurance

Patient’s (or parent’s) occupation ✔Self-employed o Student o Retired o Other: ___________________________________________

o Full-time employment o

Name of your employer: _ _________________________________________________________________________________________________________________

Address: No.__________________ Street_ __________________________________________ Suite No._ ________ City________________________________
Province_______________ Postal code_ _______________________________________ Telephone ( )_ ________________________________________

Name of spouse’s employer: ________________________________________________________________________________________________________________

Address: No.__________________ Street_ __________________________________________ Suite No._ ________ City________________________________
Province_______________ Postal code_ _______________________________________ Telephone ( ) _ _______________________________________
 Section C - Other Insurance (...continued)

Employee group benefits plan o Yes o No Group policy no.____________________________ Name of covered person____________________________________
Identification no.:_ _________________________ Name of insurance company:______________________________ Date of birth of insured (M/D/Y): _____ /_____ /_____
Any other coverage (e.g., union, pensioner, private or other policy purchased prior to your departure)
o Yes o
✔ No Policy no. _________________ Name and address of insurance company / broker: ______________________________________________________

Do you have other Credit Card Coverage? o Yes o

✔ No If yes, card no. |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

Card type/Bank___________________________________________________ Name of cardholder _ ___________________________________________________

YOUR TRAVEL INSURANCE PLAN PROVIDES COVERAGE IN EXCESS OF YOUR PROVINCIAL HEALTH INSURANCE PLAN AND ANY OTHER APPLICABLE INSURANCE AS INDICATED IN
YOUR CERTIFICATE. YOU MUST SIGN AND DATE THE FOLLOWING SECTION FOR GLOBAL EXCEL MANAGEMENT INC. TO SEEK REIMBURSEMENT FROM THESE SOURCES.

Section D - AUTHORIZATION TO PHYSICIANS, HOSPITALS, AND OTHER MEDICAL PROVIDERS

1. In order to investigate your claim, we will be collecting information about you and, if 4. You hereby assign to Royal & Sun Alliance Insurance Company of Canada and Global Excel
relevant, any other persons entitled to coverage under the policy (“Personal Information”). Management Inc. any benefits obtainable from other sources for covered losses under the
You hereby authorize any hospital, physician, or medical facility to send us your medical policy. You also direct these sources to forward payment to Global Excel Management Inc.
information. with regard to these losses.
2. By providing us with personal information about a third party such as a family member, 5. You warrant that neither you nor any other persons entitled to coverage under the policy
traveling companion, director, officer or employee, you represent that you have obtained have any additional coverage through any other insurer (other than that listed above).
their consent to the disclosure of their personal information. 6. You understand that coverage shall be void if, whether before or after the loss, any person
3. We will only use and disclose the Personal Information provided by you for the purpose of has concealed or misrepresented any fact or circumstance concerning this claim.
investigating and settling your claim. In some cases, we may disclose Personal Information 7. By proceeding with the claims process, you are consenting to the collection, use and
to other parties if they are involved in providing you services, have been engaged by us disclosure of your Personal Information as set out in this claim form and our Privacy Policy.
to assist in the processing of claims, or are responsible for losses covered under the policy. A copy of our Privacy Policy can be found at www.globalexcelservices.com. If you have any
questions about our Privacy Policy or the treatment of your Personal Information, please
call us at 1-866-363-3338.
01 01 2020
Patient or authorized person’s signature Date / / (M/D/Y)

FOR COMPANY
USE ONLY Fraud Verification A: Fraud Verification B: