Participant Information

Policy Number: More information
Certificate
Sub-group:
Certificate:
Employer:
Policy Number: Tool tip
The policy number can be written in 3 different ways : 111222333 or 1112223334 or 111222333-4 (digits or characters)
Email:
Confirm Email:
Last Name:
First Name:
Gender: Male Female
Date of Birth:
Telephone No. (day):
Ext.:
Change my Address

Information regarding the claim

Select here if you are filling a claim for your spouse or your dependent children.
Last Name: Date of Birth:
First Name: Relationship:
Delete this entry

Were any of the expenses claimed incurred outside of Canada? Yes No

Please indicate the date the claimant left his or her province of residence. Please be sure that the amounts and the currency are clearly indicated on each receipt. All amounts eligible for reimbursement will be converted to Canadian dollars.
Departure Date:

Are any of the expenses claimed the result of a work place accident? Yes No

Have you submitted a claim to a work place accident compensation program or board of your province?
Yes No

Are any of the expenses claimed the result of an automobile accident? Yes No

Have you submitted a claim to an automobile accident compensation program or board of your province?
Yes No

Coordination of Benefits

Select here if, at the time the expense was incurred, you or your spouse had health insurance coverage with another insurer.

Health and Dental Budget

Select here if you have an Health and Dental Budget.

Attachments

IMPORTANT: Please attach your receipts separately (e.g.: receipts, medical notes, etc.)

- Maximum size per file: 2 Mo.
- Maximum size of all files: 8 Mo.
- 1 attachment per receipt.

Don't forget about direct deposit!

Thanks to direct deposit, claim payments can be deposited directly into your bank account.

Signing up is easy, and processing is free and quick. Click here to complete the form and send it back to us by postal mail or by email at : individualinsurance@humania.ca.

Signing up is easy, and processing is free and quick. Click here to complete the form and send it back to us by postal mail or by email at : adm.coll@humania.ca.

Submit claim

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