Life and Health Request Form

If you have a client access user ID and password, please click here to log in to Client Access and submit your request from there. If not, please fill out and submit this form and a user ID and password will be assigned to you.

You will have the option to add additional subjects and upload attachments after submitting this form.

Your Information

* - required fields
Name: * Phone: *
Company: * On behalf of:
City: * Fax:
Quoteback Claim #: E-mail: *
Claim Department: *

Investigation Requested

Type of Investigation: Specific Task Assignment Activities Check Accidental Death Claim
Comprehensive Claimant Interview Surveillance Contestable Death Claim
Hospital and/or Physician Locate Financial Recovery
Medical Examination Contestable Disability Claim Locate Current Address
Police Report Coroner's Report Locate Current Employment
Judgment Judgment Amount  
Budget:

Report On

Name (first/last): * Date of birth: (mm/dd/yyyy)
SIN #: Telephone #:
Residence Address: Business Address:
Residence Province: * Business Province:
Residence Postal Code: Business Postal Code:
Employer: Occupation:
Date Insured: (mm/dd/yyyy) Monthly Indem or Amount of Insurance:
Claim is for: Date of disability or date of death: (mm/dd/yyyy)
Date, Place & Type of Accident: Place of Death:
Hospital(s) - Name, City & dates Confined: Cause of Death:
Specialists Seen: Attending Physician (s)/Coroner's - Name & Address:
Obtain Hospital Records? Interview Physician?
Obtain Physician's Records? Contact Employer?
Claimant (Beneficiary) & Relationship: Address & Phone Number:
If SURVEILLANCE - Description (Height, Weight, Build, Distinguishing Characteristics): Name any Attorney, Person(s) or Other Entity who (that) should not be contacted:
Interview Claimant if feasible?
 
Instructions: