The Co-operators - How To Make A Claim

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A separate claim must be filed for the loss when a family member or travelling companion is insured under a different policy number.

Items marked with * are required. Please also complete all relevant information in any non-mandatory fields as it pertains to your claim. Depending on the claim, additional information may be requested.

Personal Information

*Title

*First name

*Last name

*Date of Birth

Insured's complete mailing address

*Street Address

Street Address line 2

*City

*Province/State

*Postal/ZIP Code

Contact Information

*Telephone number
	including area codes

Fax number
	including area codes

Language
	Main language/dialect spoken if other than English

Email Address
	Note: It is important that the security setting of your email account is set properly to avoid our reply e-mails being put into your spam folders

TIC Policy Information

*Policy Number

*Plan

*Purchase Date
	yyyy-mm-dd Date your insurance was purchased

*Agency/Broker
	Name of Insurance agency/broker where you purchased your insurance

Trip information

*Scheduled departure date

*Scheduled Return Date

New Return Date

*Purpose of Trip

Patient information

First name

Last name

Relationship to Insured

Physician Information

Usual family physician

Full name

Telephone number
	including area codes

Street Address

City

Province/State

Postal/ZIP Code

Other treating physician

Full name

City

Province/State

Postal/ZIP Code

Family members/travelling companions

Number of travelling companions / family members

First name

Last name

Date of Birth

Relationship to Insured

Claim information

*Payment method
	Method of payment used to pay for your travel arangements

If credit card, please provide first 6 digits
	* used only to verify eligibility for credit card insurance

When did your loss occur?

Cancellation cause date
	Date cause of cancellation first occured

Agent cancellation date
	Date you cancelled with Travel Agent/Airline

Cancellation circumstances
	Describe the circumstances which resulted in cancellation or interruption of your trip. If due to medical reasons, please include symptoms and diagnosis of sickness, or details of cause of injury. If due to a death, provide cause and date of death, and relationship of deceased to Insured.

Expenses

Number of expenses

Date
	Date of expense

Type of expense

Cost

Currency

Additional Information

Additional information

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