Critical illness claim forms
How to make a claim
If you have coverage through your employer or plan sponsor, use these forms to apply for critical illness benefits, either for you or your child.
Step 1: Complete a claimaint statement.
Download this form and fill it out in Adobe Reader XI or higher - Opens in a new window (not your browser) and save.
Use this form to describe the nature and extent of your accident or critical illness.
Step 2: Ask your doctor to complete a report.
Choose the most appropriate form for your condition and ask your doctor to complete it.
You and your physician must fill in this form relating to treatment of a benign brain tumour. Submit this completed form as part of your claim.
Use this form to describe the nature and extent of your accident or critical illness.
A physician will need to fill in this form relating to treatment for a coma. Submit this completed form as part of a claim.
You and your physician must fill in this form relating to treatment of aplastic anemia. Submit this completed form as part of your claim.
You and your physician must fill in this form relating to treatment of bacterial meningitis. Submit this completed form as part of your claim.
You and your physician will need to fill in this form relating to cancer treatment. Submit this completed form as part of your claim.
You and your physician must fill in this form relating to coronary artery bypass surgery. Submit this completed form as part of a claim.
You and your physician will need to fill in this form for treatment relating to hearing loss. Submit this completed form as part of a claim.
Your physician must fill in this form relating to treatment of dementia and Alzheimer's. Submit this completed form as part of your claim.
You and your physician must fill in this form for claims relating to a heart valve replacement. Submit this completed form as part of a claim.
A physician must fill in this form regarding loss of independence. Submit this completed form as part of a claim.
You and your physician will need to fill in this form for treatment relating to loss of speech. Submit this completed form as part of a claim.
You and your physician must fill in this form for treatment relating to an organ transplant. Submit this completed form as part of a claim.
You and your physician must fill in this form to confirm the diagnosis of multiple sclerosis. Submit this completed form as part of a claim.
You and your physician must fill in this form to confirm the diagnosis of occupational HIV. Submit this completed form as part of a claim.
You and your physician must fill in this form to confirm the onset of full or partial paralysis. Submit this completed form as part of a claim.
You and your physician must fill in this form to confirm the onset of Parkinson's disease. Submit this completed form as part of a claim.
You and your physician will need to fill in this form to confirm treatment for a stroke. Submit this completed form as part of a claim.
Your physician must fill in this form relating to aortic surgery. Submit this completed form as part of your claim.
You and your physician will need to fill in this form relating to treatment of blindness. Submit this completed form as part of your claim.
You and your physician will need to fill in this form for treatment relating to a heart attack. Submit this completed form as part of a claim.
You and your physician must fill in this form for treatment relating to the loss of limbs. Submit this completed form as part of a claim.
You and your physician must fill in this form to confirm the diagnosis of motor neuron disease. Submit this completed form as part of a claim.
You and your physician will need to fill in this form for treatment relating to severe burns. Submit this completed form as part of a claim.
You and your physician will need to fill in this form for treatment relating to kidney failure. Submit this completed form as part of a claim.
Step 3: Ask your employer or plan sponsor to complete an employer statement.
They should have this form already.
Step 4: Submit your claim.
Once you have these three forms completed, email them to us at groupciclaims@canadalife.com.