Fillable CLAIM FOR HEALTH CARE BENEFITS (Desjardins Insurace)

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CLAIM FOR HEALTH CARE BENEFITS (Desjardins Insurace)

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19132A (2020-01) Page 1 of 2
Group Insurance - Health Claims
CLAIM FOR HEALTH CARE BENEFITS
 
Name of group or policyholder or employer
Member's last name and rst name Sex Date of birth
Address - Number, street, apartment City Province Postal code
M
F
YYYY MM DD
I do not wish to use my Health Spending Account.
Ineligible expenses - I wish to use my Health Spending Account to cover the expenses that are not reimbursed under my group insurance plan.
Spouse's family coverage - I wish to use my Health Spending Account for myself and my dependent children to cover the expenses that are not reimbursed
under my group insurance plan. I will not submit a claim to my spouse's insurer (coordinaon of benets).
I conrm that I am eligible for a reimbursement of the indicated expenses under my Health Spending Account.
I recognize that I am responsible for paying any taxes that may result from the reimbursement of these expenses and that, for tax or administrave purposes, my
plan administrator may have access to a statement of expenses for which I claimed a reimbursement under my Health Spending Account.
D
HEALTH SPENDING ACCOUNT - If you have this benet, check the opon you would like.
4
If your claim is for one of your dependents, accident-related expenses, or out-of-province expenses, please complete the appropriate
on the back of the form.
C.P. 3950, Lévis (Québec) G6V 8C6
4
Desjardins Insurance, life, health, rerement logo
Do you want your claim processed within 2 business days? To nd out more about our online and mobile services and the direct deposit service, please visit desjardins life insurance.com/planmember.
Do you want your claim processed within 2 business days?
Visit  
ü
Online and mobile services
ü
Direct deposit
A IDENTIFICATION - MANDATORY SECTION -
This informaon can be found on your insurance cercate or payment card.
Last name and rst name of person who has the other insurance plan Sex Date of birth
Name of insurer Period of coverage
Type of benets: Drugs Dental care Supplementary health care Vision care Travel
Type of coverage: Individual Couple Single-parent Family
From To
M F
Other
Desjardins
Insurance - Contract no.: Cercate no.:
YYYY MM DD
YYYY MM DD
Transit/branch no. Instuon no. Account no.
Your email address (mandatory)
YYYY MM DD
Last name and rst name of the
dependents covered under this
other insurance plan
1.
2.
3.
4.
If you are covered by more than one insurance plan, the coordinaon of benets may entle you to a reimbursement of up to 100% of your eligible expenses.

1. The person who has the other insurance plan must submit a claim to their own insurer rst and then provide Desjardins Insurance with detailed informaon
about the benets paid (informaon found on the explanaon of benets), as well as copies of any receipts.
2. Claims for dependent children must rst be submied under the plan of the parent whose birthday (month and day) comes rst in the calendar year.
C COORDINATION OF BENEFITS
Once registered, your reimbursements for health care services will be deposited into this bank account. A nocaon email will be sent once your claims have
been processed, and the explanaon of benets will be posted online rather than mailed. You must be registered on the secure site to consult your explanaon of
benets. To register, go to desjardinslifeinsurance.com/planmember.
Desjardins Financial Security Life Assurance Company (DFS), hereinaer Desjardins Insurance, is not responsible for the accuracy of the banking informaon you
enter and for verifying that the due amounts are deposited into your account.
B DIRECT DEPOSIT SERVICE -
Aach a void cheque or provide your bank informaon below to sign up for direct deposit.
VOID
001
$
Branch no. Institution no. Account no.
⑈033 ⑈
⑆04334 ⑉0 01 ⑆
111 ⑉112⑉1 ⑈
⑈033⑈ ⑆0 4334⑉0 01⑆ 111 ⑉112⑉1⑈
Address C. P. 3950 Lévis Québec G 6 V 9 X 8 web site desjardins life insurance dot com slash plan member Telephone 1 8 0 0 2 6 3 1 8 1 0
Page 2 of 2

Desjardins Insurance handles the personal informaon it has on you in a condenal manner. Desjardins Insurance keeps this informaon on le so that you may
benet from group insurance services oered by the Company. This informaon is consulted solely by Desjardins Insurance employees who need to do so in the
course of their work. Desjardins Insurance may compile anonymized personal informaon for stascal and informaonal purposes. Desjardins Insurance may
also communicate with plan members to provide them with opmal health management. You have the right to consult your le. You may also have informaon
corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a wrien request to the following address: Privacy
Ocer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list to oer its clients an insurance
product following the terminaon of their group insurance. If you do not wish to receive these oers, you may have your name removed from the list. To do so, you
must send a wrien request to the Privacy Ocer at Desjardins Insurance.
Last name and rst name of injured person
Date of accident
Is the claim the result of: A work injury?
A
motor vehicle accident?
YYYY MM DD
IMPORTANT - Please note that the claim must rst be submied under your provincial workers’ compensaon plan or automobile insurance plan (if applicable
in your province) before being submied to your group insurance plan.
Length of trip: From:
To: Desnaon: Amount claimed: $
Reason for trip:
Pleasure
Business
Receive care (please ensure that this type of trip is covered by your contract)
YYYY MM DD YYYY MM DD
Please include the original receipt itemizing all of your out-of-province expenses.
This is not a travel insurance form. Visit desjardinslifeinsurance.com/travel-claim to nd the correct form.
All the informaon I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Informaon Management secon.
I authorize Desjardins Insurance, strictly for the purposes of managing my le and seling this claim to: a) collect from any person or legal enty, or from any public
or parapublic organizaon, only the informaon deemed necessary to manage my le. The non-exhausve list of sources from which informaon may be collected
includes health care professionals or facilies, insurance companies; b) communicate to the said persons or organizaons only the personal informaon about me
that is deemed necessary for the purposes of my le; c) when necessary use the personal informaon it may have about me in exisng les that are now closed.
This authorizaon is also valid for the collecon, use and communicaon of personal informaon concerning my dependents, insofar as applicable to the claim.
A photocopy of this authorizaon is as valid as the original.
Signature of the member
 
Telephone nos: Home: Oce: Extension:
E
INFORMATION ABOUT DEPENDENTS - For the period in which expenses were incurred.
Start date
of cohabitaon:
Child born No
of this union? Yes
OR
YYYY MM DD
Date of
marriage:
Date
of birth:
YYYY MM DD YYYY MM DD
g
In the case of a change of spouse, please indicate:
1
Last name and rst name Relaon Sex Date of birth
Has a funconal impairment
Full-me student - Name of educaonal instuon aended:
Period: From: To:
YYYY MM DD
YYYY MM DD YYYY MM DD
Spouse
Child
M
F
2
Last name and rst name Relaon Sex Date of birth
Has a funconal impairment
Full-me student - Name of educaonal instuon aended:
Period: From: To:
YYYY MM DD
YYYY MM DD YYYY MM DD
Spouse
Child
M
F
3
Last name and rst name Relaon Sex Date of birth
Has a funconal impairment
Full-me student - Name of educaonal instuon aended:
Period: From: To:
YYYY MM DD
YYYY MM DD YYYY MM DD
Spouse
Child
M
F
F
INFORMATION ABOUT AN ACCIDENT-RELATED CLAIM
G 
H PERSONAL INFORMATION MANAGEMENT
I DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION

I conrm that the persons designated below meet the denion of spouse and
dependent child as specied in the contract under which this claim has been submied.
depending on the contract)
If your child has a funconal impairment, please provide us with a
medical cercate conrming your child's disability.
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CLAIM FOR HEALTH CARE BENEFITS (Desjardins Insurace)

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Completed 9 February 2021

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