Claim for health and dental benefits | Humania Assurance Inc.

Participant Information

Policy Number:
Sub-group:
Certificate:
Employer:

Policy Number:

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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I have read and I accept the conditions.

This is the default dialog which is useful for displaying information. The dialog window can be moved, resized and closed with the 'x' icon.

Street No.:
Street Name:
Unit No.:
City:
Province:
Postal Code:

	1.	I do not wish to use my Health and Dental Budget.
	2.	Expenses not covered under the base plan: I wish to use my Health and Dental Budget for any amount not reimbursed under my basic plan: Amount claimed: $
	3.	Expenses subject to coordination with another insurer: I wish to use my Health and Dental Budget for me and/or my dependent children for any portion of my claim that is subject to coordination. I will not file a claim with the insurer of my spouse: Amount claimed: $
	4.	Expense subject to a medical recommendation: I wish to use my Health and Dental Budget for any such expense for which I don't have a medical recommendation: Amount claimed: $