Visitors to Canada Medical ... - Reliable Life Insurance Company by wulinqing


									To report a claim:
Return the required documentation                      Reliable Life Insurance Company
detailed below, along with your original,              Box 557, 100 King Street West
signed, claim form to:                                 Hamilton, Ontario L8N 3K9

Visitors to Canada Medical Expense Claims

Emergency Medical Claim Form
This entire form is to be completed, signed, and dated by the insured submitting a claim for reimbursement.
Incomplete forms will be returned to you for completion which may result in a delay in the processing of your claim.

Medical Expenses

Doctor, hospital        Original receipts for any out of pocket medical expenses. Also, please submit documentation
and/or                  to support the diagnosis and treatment of the sickness or injury.

Explanation of Benefits

Primary health          Submit the paperwork you received back from your primary health care provider, showing
insurance carrier       what they paid and what was not covered.

              Underwritten by Reliable Life Insurance Company and Old Republic Insurance Company of Canada
                                  Box 557, 100 King Street West, Hamilton, Ontario L8N 3K9
                                        Phone: 1-888-831-2222 Fax: 1-866-551-1704

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