Fields marked with * are mandatory.


Using the online form

In order to use the online form, you must enroll in Direct Deposit. Do you agree to provide us with your bank information?


Are the expenses claimed on this form the result of:

- a work-related injury? *


- an automobile accident? *


- travelling abroad? *



Information about participant

Identify yourself using your group and identification numbers OR your policy number, as indicated on your insurance certificate. *

separation

This claim concerns the (Check all the applicable fields): *


Participant

Spouse

Children

General information

Title *

Telephone (home) *
-

Telephone (work)
-


Your email address will not be used for solicitation purposes.
Bank information

If you have not provided your banking information, you must attach a scanned copy of a cheque specimen, unsigned and marked « VOID » or a photograph in .jpg, .png or .pdf format. To expedite processing, make sure the image is clear and legible.

Choose a file
supprimer
Spouse
Children

Date of birth *

Full-time student * (Check yes only if your dependent child, a full-time student, is age 18 or over)



IMPORTANT: La Capitale reserves the right to ask you for a confirmation of student status.

Start date of the school year *

End date of the school year *



Full name Date of birth Full-time students Start End
Coordination of benefits

Are your spouse or dependent child covered under another plan?*

The following process applies when both spouses have insurance coverage:

a) Your spouse first submits his or her claim to his or her insurance company; then, your spouse submits details of the benefits paid and photocopies of the receipts to La Capitale.

b) Claims for dependent children are submitted to the insurance company of the parent whose birthday falls first in the year.


Insurance start date *

Receipts

You must provide us with a clear scanned copy or a photograph, in .jpg, .png or .pdf format. To expedite processing, make sure the image is clear and legible. The total size of the files containing your receipts should not exceed 10 MB.

I have read and accept the conditions stipulated by La Capitale Civil Service Insurer Inc. related to prescription drug, medical and paramedical expense claims.


Please print this duly completed claim form for your records.