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Vision contract - Claim forms

Quebec

Disability

  1. Disability claim – Disabled person’s statement – 17001E (PDF, 399 KB) - This link will open in a new window.
  2. Disability claim – Employer or self-employed individual’s statement – 17002E (PDF, 440 KB) - This link will open in a new window.
  3. Physical Illnesses – RACQ – Original request – 020255A (PDF, 317 KB) - This link will open in a new window.
  4. Physical Illnesses – RACQ – Additional report – 020265A (PDF, 179 KB) - This link will open in a new window.
  5. Claim for benefits following an accident – 17003E (PDF, 534 KB) - This link will open in a new window.
  6. Claim for loss of employment benefits – 17004E (PDF, 361 KB) - This link will open in a new window.
  7. Authorization for the collection and communication of personal information (Disability) – 980185E (PDF, 284 KB - This link will open in a new window.
  8. Additional statement regarding a disability – Employer or self-employed individual’s statement – 17011E (PDF, 245 KB) - This link will open in a new window.

Death

  1. Critical Illness claim form – Insured's statement – 17025A (PDF, 123 KB) - This link will open in a new window.
  2. Critical Illness claim form – Cancer – heart attack – stroke or other illness – Attending physician's statement – 17026A (PDF, 95 KB) - This link will open in a new window.
  3. Claimant's statement – Death claim – 98069E (PDF, 58 KB) - This link will open in a new window.
  4. Authorization for the collection and communication of personal information (Death) – 06024E (PDF, 37 KB) - This link will open in a new window.

Rest of Canada

Disability

  1. Disability claim – Disabled person’s statement – 17001E01 (PDF, 398 KB) - This link will open in a new window.
  2. Disability claim – Employer or self-employed individual’s statement – 17002E01 (PDF, 440 KB) - This link will open in a new window.
  3. Physical Illnesses – Original request – 14270E (PDF, 328 KB) - This link will open in a new window.
  4. Physical Illnesses – Additional report – 14271E (PDF, 329 KB) - This link will open in a new window.
  5. Authorization for the collection and communication of personal information (Disability) – 98185E02 (PDF, 151 KB) - This link will open in a new window.
  6. Additional statement regarding a disability – Employer or self-employed individual’s statement – 17011E01 (PDF, 398 KB) - This link will open in a new window.

Death

  1. Critical Illness claim form – Insured's statement – 17025A (PDF, 123 KB) - This link will open in a new window.
  2. Critical Illness claim form – Cancer – heart attack – stroke or other illness – Attending physician's statement – 17026A (PDF, 95 KB) - This link will open in a new window.
  3. Claimant's statement – Death claim – 98069E (PDF, 58 KB) - This link will open in a new window.
  4. Authorization for the collection and communication of personal information (Death) – 06024E (PDF, 37 KB) - This link will open in a new window.

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