Forms

Administration

Claim

Underwriting

Administration

• Authorization to collect personal information (PDF – 50 Ko)
• Declaration of health (PDF – 40 Ko)
• Declaration of health short form – Reinstatement (PDF – 58 Ko)
• Declaration of health - Accident Only (Superior Program) (PDF - 161 Ko)
• Legal change request (PDF – 71 Ko)
• Modification to the effective date of contract - Acci-Jet Program (PDF - 23 ko)
• Need analysis (PDF - 61 Ko)
• Overhead Expense Insurance (PDF – 51 Ko)
• Overhead Expense Insurance for Farm Enterprises (PDF – 50 Ko)
• Overhead Expense Insurance for Truck Ownerse (PDF – 50 Ko)
• Pre-authorized Debit Agreement (PDF – 75 Ko)
• Reinstatement form Excel Hospitalization (PDF – 49 Ko)
• Reinstatement form Excel Life (PDF – 50 Ko)
• Trucker - Driver - Transport driver (PDF – 54 Ko)

Claim

Individual Insurance

Acci7

• Claim form for Acci7 (PDF – 41 Ko)

     Acci-Jet Program

• Authorization (PDF - 42 Ko)
• Determining the amount of the monthly benefit (PDF - 140 Ko)
• Overhead Expenses Claim Form (PDF - 55 Ko)
• Statement by Attending Physician (PDF – 208 Ko)
• Statement of Claimant (PDF - 68 Ko)
• Statement of Income and job description (PDF - 28 Ko)
• Statement of Return to Work (PDF - 133 Ko)

      Accxel

• Accidental Dismemberment and Loss of Signs (PDF – 206 Ko)
• Authorization RAMQ (PDF – 52 Ko)
• Dental Claim Form (PDF – 365 Ko)
• Hospitalization Insurance Claim Form (PDF – 871 Ko)
• Individual Insurance Claim & Proof of Death (PDF – 55.2 Ko)
• Medical Expenses and accident insurance claim (PDF – 743 Ko)
• Monthly Benefit Declaration of Disability (PDF – 580 Ko)
• Overhead Expenses Claim Form (PDF – 55 Ko)
• Statement of Return to Work (PDF – 133 Ko)

Accident Health Insurance

• Accident Health Insurance Benefit (PDF – 23 Ko)

Superior Program

• Authorization (PDF – 42 Ko)
• Authorization RAMQ (PDF – 52 Ko)
• Determining the amount of the monthly benefit (PDF - 140 Ko)
• Overhead Expenses Claim Form (PDF – 55 Ko)
• Overhead Expenses eligible vehicle Expenses (PDF - 100 Ko)
• Statement of Attending Physician (PDF – 83 Ko)
• Statement of Claimant (PDF – 68 Ko)
• Statement of Income and job description (PDF - 28 Ko)
• Statement of Return to Work (PDF – 133 Ko)

Universal Loan Insurance

• Authorization (PDF – 42 Ko)
• Authorization RAMQ (PDF – 52 Ko)
• Statement to be made by Employer or by Self-employed (PDF – 52 Ko)
• Statement of Attending Physician (PDF – 83 Ko)
• Statement of Claimant (PDF – 80 Ko)
• Statement of Return to Work (PDF – 133 Ko)

Life Insurance

• Authorization RAMQ (PDF – 59 Ko)
• Authorization to collect information (PDF – 48 Ko)
• Individual Insurance Claim & Proof of Death (PDF – 55 Ko)

Hospitalization Insurance

• Claim form accident health insurance benefit (PDF – 29 Ko)
• Hospitalization Insurance Claim Form (PDF – 871 Ko)

Travel Insurance

• Claim Form (PDF – 27 Ko)
• Hospital and Medical Expenses (PDF - 44 Ko)

• Trip Cancellation (PDF - 100 Ko)

MRA groups

Underwritting

• Authorization (PDF – 52 Ko)
• Aviation or Aerial Sports (PDF – 60 Ko)
• Back (PDF – 58 Ko)
• Bowel disorders (PDF – 57 Ko)
• Cardiovascular disorders (PDF – 57 Ko)
• Climbing or mountaineering (PDF – 56 Ko)
• Diabetes (PDF – 59 Ko)
• Digestive disorders (PDF – 58 Ko)
• Driving record (PDF – 57 Ko)
• Drug use (PDF – 56 Ko)
• Epilepsy (PDF – 57 Ko)
• Joints (PDF – 57 Ko)
• Motor sports (PDF – 56 Ko)
• Nervous disorders (PDF – 57 Ko)
• Out-of-country travel or stays (PDF – 57Ko)
• Pulmonary disorders (PDF – 59 Ko)
• Rider (PDF – 53 Ko)
• Tobacco use (PDF – 56 Ko)
• Trucker driver - Transport driver (PDF – 54 Ko)
• Underwater diving (PDF – 58 Ko)
• Urinary disorders (PDF – 58 Ko)