Notice of loss

Type of loss *

Complete this Notice immediately to inform the Company of any event involving the insured.
This Notice should be mailed within 30 days of the date of the event to LS Mutual Life Insurance Company, P.O. Box 10 000, Saint-Hyacinthe(Québec) J2S 7C8 1-800-773-8404.
Upon receipt if this notice, the Head Office Benefits Department will contact you as soon as possible.

Coordinates of the insured

Last name *

First name *

Address

N° *

Street *

City *

Province *

Postal code *

Phone *

Policy n° *

Date of birth *

Date of event *

Last name of policyholder *

First name of policyholder *

Circumstances of the accident *

Nature of injury *

Cause of death *