Medical Claim Form - www.seafarers.ca

Seafarer Information

Name

First

Last

Date of Birth

Union Reference Number

Found in your membership book

Phone Number

Email Address

Union Number

Found in your membership book

Reference Layout Claim

Residential Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Employment Information

Employer Name

Name of Last Ship

Incident/Claim Information

You can upload up to three separate claims below for a single individual. If you are filing a claim for multiple individuals, please file them using separate forms for each person/claimant. If you only have one claim to submit, fill out the first claim section and proceed below.

Patient Information (if different from policyholder)

Name

Date of Birth

If any of the claims indicated below is for the Seafarers’ spouse, is he/she covered by any other insurance for this type of claim?

Yes
No
Not applicable

Relationship to Policy Holder

Address (if different)

Is the seafarers’ spouse also a seafarer?

Yes
No

Claim #1

Date of Service (claim 1)

Total Amount Claimed (claim 1)

Upload Invoice / Receipt (claim 1)

Drag & Drop Files, Choose Files to Upload

Description of Services (claim 1)

Reason for visit (claim 1)

Claim #2

Date of Service (claim 2)

Description of Services (claim 2)

Total Amount Claimed (claim 2)

Reason for visit (claim 2)

Upload Invoice / Receipt (claim 2)

Drag & Drop Files, Choose Files to Upload

Claim #3

Date of Service (claim 3)

Description of Services (claim 3)

Total Amount Claimed (claim 3)

Reason for visit (claim 3)

Upload Invoice / Receipt (claim 3)

Drag & Drop Files, Choose Files to Upload

Authorization and Consent

Consent

I authorize the release of any medical information necessary to process this claim. I hereby certify that all of the above information is true and that the documents submitted herewith are authentic. Should any of the same documents submitted on my behalf be found to have been falsified, I will be liable to suspension of further benefits.

Policyholder's Signature

Clear Signature

Date of Signature