Notice of loss

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Avis de sinistre

Please fill in the form below

Type of loss*(Required)

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 Humania Assurance Inc., Saint-Hyacinthe, Quebec J2S 2Z6 / Tel.:1-800-773-8404.
Upon receipt if this notice, the Head Office Benefits Department will contact you as soon as possible.

First name*(Required)

Last name*(Required)

Address

N°*(Required)

Street*(Required)

City*(Required)

Province*(Required)

Postal code*(Required)

Phone*(Required)

Policy number*(Required)

Date of birth*(Required)

Date of event*(Required)

Last name of policyholder*(Required)

First name of policyholder*(Required)

Circumstances of the accident*(Required)

Nature of injury* (Required)

Cause of death*(Required)

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