Dental Claim Form - www.seafarers.ca

If you require a PDF version of the form below, please email medical@seafarers.ca to receive a copy.

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

any Address the

Residential Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Employer Name

Name of Last Ship

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?

Relationship to Policy Holder

Address (if different)

Is the seafarers’ spouse also a seafarer?

Date of Service

Total Amount Claimed

Upload Invoice / Receipt

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Description of Services

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