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Vision contract - Claim forms

Claim forms for Quebec / Rest of Canada

  1. Authorization for release of information (CPP) (PDF, 55 KB) - This link will open in a new window.
  2. Authorization for release of information (RRQ) (PDF, 65 KB) - This link will open in a new window.
  3. Authorization for the collection and communication of personal information (Death) (PDF, 37 KB) - This link will open in a new window.
  4. Authorization for the collection and communication of personal information (Disability) (PDF, 62 KB) - This link will open in a new window.
  5. Authorization for the release of information - CSST (PDF, 78 KB) - This link will open in a new window.
  6. Claim - Individual Insurance - accidental dismemberment or loss of sight - fractures (PDF, 130 KB) - This link will open in a new window.
  7. Claim - Total Long-term Care - Independent Living - Loss-of-independence Coverage (PDF, 177 KB) - This link will open in a new window.
  8. Claim for benefits following an accident (PDF, 57 KB) - This link will open in a new window.
  9. Claim for loss of employment benefits (PDF, 91 KB) - This link will open in a new window.
  10. Claimant's statement - Death claim (PDF, 58 KB) - This link will open in a new window.
  11. Critical Illness claim form - Cancer - heart attack - stroke or other illness - Attending physician's statement (PDF, 95 KB) - This link will open in a new window.
  12. Critical Illness claim form - Insured's statement (PDF, 123 KB) - This link will open in a new window.
  13. Disability claim - Employer or self-employed individual's statement (PDF, 109 KB) - This link will open in a new window.
  14. Disability claim - Individual (PDF, 108 KB) - This link will open in a new window.
  15. Disabled Person's Supplementary Statement Disability (PDF, 66 KB) - This link will open in a new window.
  16. Physical Illnesses - RACQ - Additional report (PDF, 62 KB) - This link will open in a new window.
  17. Physical Illnesses - RACQ - Original request (PDF, 62 KB) - This link will open in a new window.
  18. Pre-authorized debit agreement (PAD) - Payor's authorization (PDF, 42 KB) - This link will open in a new window.

Claim forms - Quebec (in French)

  1. Déclaration complémentaire de la personne invalide (PDF, 89 KB) - 2121001 - This link will open in a new window.
  2. Déclaration du réclamant - Décès (PDF, 99 KB) – 98069 - This link will open in a new window.
  3. Déclaration du statut professionnel - Invalidité (PDF, 78 KB) - 10255 - This link will open in a new window.
  4. Déclaration du statut professionnel - Perte d'emploi (PDF, 81 KB) - 10256 - This link will open in a new window.
  5. Déclaration relative aux frais d'affaires (PDF, 104 KB) - 09110 - This link will open in a new window.
  6. Déclaration supplémentaire relative à une invalidité (PDF, 93 KB) - 09045 - This link will open in a new window.
  7. Demande de prestations pour maladies graves ou redoutées - Rapport du médecin traitant (PDF, 73 KB) - 17026 - This link will open in a new window.
  8. Demande de prestations relative à une invalidité (PDF, 204 KB) - 09044 - This link will open in a new window.
  9. Demande de prestations - assurances individuelles - Perte accidentelle de membre ou de la vue - Fracture (PDF, 109 KB) - 03031 - This link will open in a new window.
  10. Demande de prestations à la suite d'un accident - Vision (PDF, 55 KB) – 00107F02 - This link will open in a new window.
  11. Demande de prestations d'assurance invalidité - Déclaration de l'employeur ou de la personne à son compte (PDF, 79 KB) – 0202452 - This link will open in a new window.
  12. Demande de prestations d'assurance invalidité - Déclaration de la personne invalide (PDF, 52 KB) - 0202451 - This link will open in a new window.
  13. Demande de prestations pour perte d'emploi (PDF, 93 KB) – 00107F03 - This link will open in a new window.
  14. Demandes de prestations pour maladies graves ou redoutées - Déclaration de l'assuré (PDF, 120 KB) – 17025 - This link will open in a new window.
  15. Engagement à rembourser des prestations d'invalidité payées en trop par l'assureur (hors Québec) (PDF, 61 KB) - 07147F01 - This link will open in a new window.
  16. Engagement à rembourser des prestations d'invalidité payées en trop par l'assureur (Québec) (PDF, 63 KB) - 07147 - This link will open in a new window.
  17. Maladies à caractère physique - Demande initiale (PDF, 64 KB) - 020255 - This link will open in a new window.
  18. Maladies à caractère physique - Rapport supplémentaire (PDF, 70 KB) - 020265 - This link will open in a new window.
  19. Rapport médical suite à une hospitalisation (PDF, 67 KB) - 03034 - This link will open in a new window.
  20. Rente soins de longue durée - Vie autonome (PDF, 196 KB) - Protection perte d'autonomie - 06223 - This link will open in a new window.
  21. Autorisation à la collecte et à la communication de renseignements personnels (invalidité) (PDF, 58 KB) - 98185 - This link will open in a new window.
  22. Autorisation à la collecte et à la communication de renseignements personnels (décès) (PDF, 72 KB) – 98185F01 - This link will open in a new window.
  23. Autorisation à la divulgation de renseignements (CSST) (PDF, 40 KB) – 05172 - This link will open in a new window.
  24. Autorisation de divulgation de renseignements (RPC) (PDF, 55 KB) - 15803 - This link will open in a new window.
  25. Autorisation de divulgation de renseignements (RRQ) (PDF, 55 KB) – 1580311 - This link will open in a new window.

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