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Date the trip was purchased
Date the trip was cancelled
with the travel provider
Cost of trip $
Amount claimed $
IMPORTANT – Required information to process your claim
Was the trip purchased from a travel agency in the province of Quebec?
If " Yes", have you submitted and received a reponse from the OPC?
Yes No
Yes No
If you answered " Yes" to both questions, please attach a copy of the decision rendered by the OPC
Original return date
Planned destination (city and country)
Have you obtained a credit or refund from your service provider(s)?
Yes No
If " Yes", please attach a copy of the service provider’s answer and ensure the details of the refunds and credits received are listed in the table below
Ex. : Vacation package ABC wholesaler $1,000 $250 $750$
Expenses & Fees Claimed (paid with your credit card)
$ $ $
$ $ $
$ $ $
$ $ $
$
Agreement, Authorization, and Subrogation
SEND THE DULY COMPLETED FORM ALONG WITH ALL OTHER REQUIRED DOCUMENTS TO CANASSISTANCE
By email:
claims@canassistance.com
Send all scanned documents and keep all originals for at least 1 year
following submission of your claim.
By regular mail:
CanAssistance, Travel Claims Department
1981, McGill College Avenue, Suite 400, Montreal, Quebec H3A 2W9
COVID-19
CLAIM FORM – TRIP CANCELLATION INSURANCE
Year Month Day
Year Month Day
Original departure date
Year Month Day
Year Month Day
Fee description
Trip provider
(supplier, carrier, online purchase, etc.)
Amount paid (CAD)
Reimbursement and credits
already received (CAD)
Claimed amount
(CAD)
1. I hereby certify that I have not received any compensation for this loss giving rise to this claim other than that declared in this form.
2. I certify that I have not in any way caused or attempted to cause, directly or indirectly, this loss. I have not concealed or misrepresented any circumstances or any
relevant facts regarding this coverage and its purposes.
3. I hereby agree to assign to CanAssistance Inc. all benefits payable by third parties for losses covered under the policy. Furthermore, following the application for
reimbursement from CanAssistance Inc., I authorize third parties to pay CanAssistance Inc., the benefits payable regarding these losses.
4. To assess my application for benefits, I authorize insurance companies, airline companies, travel agents and any other organization or person who have information
about me or the loss leading to my claim, to convey that information to CanAssistance inc. Further, I authorize CanAssistance inc. to provide my information to the insurer
of my travel policy and to its reinsurers, to internal and external auditors and to any professional or organization mandated by CanAssistance inc. within the context of my
claim.
5. I declare that the information and details given on this form and the information provided in the attached documents are complete and true, and I am aware that any
false declaration shall nullify the insurance certificate or insurance policy and shall result in the denial of my application for benefits.
6. In consideration of the benefits to be paid as per my policy, I hereby assign and subrogate to my insurer, my rights and remedies against anyone and any person who
may be responsible or liable for amounts, damage, loss and/or injuries suffered by me and/or one or more of my family members, covered under my contract, up to all
the amounts that will be paid by my insurer and thus hereby subrogate my insurer in all my rights and remedies for the said amounts.
7. I agree to accept no settlement without the prior approval of my insurer, failing which all amounts paid by my insurer will be reimbursed to it without delay, and I agree
and accept to reimburse my insurer any amount that I receive from anyone and any person who may be responsible or liable for such amounts, damage, loss and/or injury
or from any person liable for it, up to the amount paid by my insurer.
Date :
Signature of Policyholder or legal heir :
Signature of Spouse if he or she is claiming :
Signature of the dependant, if she or he is of legal age :
Date :
Date :
