To submit a claim, you can:
 

• dial 1-877-886-5042 (toll-free); or
• use the print-ready Claim Form.
   

How to Print and Submit the Form

1)  Print the Claim Form.

   1 page - 50 kb

You will need Adobe Reader to view and print the form. To download the program free of charge, click here:

Download Adobe Reader

2)  Complete the form.
3)  Attach all required documents.
4)  Send the form and documents to the address mentioned in the form.

A summary of amounts paid and eligible expenses under each Accirance coverage option is available for consultation. To see the complete list, refer to the Distribution Guide or your Accirance policy.

Required Documentation

Special Situations
In certain circumstances, in addition to the usual documents (see "Claim Type and Related Documents" below), you must also submit the following:
 

• Group insurance for hospital and paramedical expenses
  If you are covered by group insurance for hospital and paramedical expenses, attach a copy of your group-insurance remittance slip or payment summary.

• Industrial accidents, vehicular accidents, criminal injuries, accidents outside Canada
  Attach a copy of the payment summary from the organization in question:
   
  • Industrial Accidents: Quebec Workers' Compensation (CSST)
  • Vehicular Accidents: Quebec Motor Vehicle Bureau (SAAQ)
  • Criminal Injuries: Crime Victims' Indemnity Commission (IVAC)
  • Accidents Outside of Canada: Quebec Health Insurance Board (RAMQ)
     

Claim Type and Related Documents
Below are the basic documents to be submitted, depending on the type of claim in question. In certain circumstances, you may be asked for other documents as well.
 

• Accidental Death, Fracture, Dismemberment or Loss of Use
• Non-Accidental Death
• Hospital and Paramedical Coverage
• Dental Care Coverage
• Transportation and Accommodation Coverage
• Educational Costs
• Compensation for Loss of Summer Job (students 17 through 24)
• Disappearance of an insured child
   

Accidental Death, Fracture, Dismemberment or Loss of Use

Accidental Death

• Photocopy of birth certificate; and
• Original or certified copy of death certificate; and
• The coroner's report:
   
  • In the case of a vehicular accident if the insured was a passenger in the vehicle, the coroner's preliminary report.
     

Fracture

• Claims for $50.00 or less: No medical certificate is necessary.
• Claims for $120.00: A medical certificate* is necessary only if you have submitted a claim in the past five years.
• Claims for more than $120.00: A medical certificate* is necessary.
   

* Medical Certificate:

• Radiographic protocol or photocopy of radiographic report (8.5" x 11"); or
• Doctor's order specifying name of bone and bearing physician's signature; or
• Medical report.
   

Dismemberment or Loss of Use

• Copy of medical file since date of accident
   

Non-Accidental Death

Natural Death (insured aged more than 14 days and less than 25 years)

• Photocopy of birth certificate; and
• Original or certified copy of death certificate; and
• Medical report specifying the exact cause of death.
   

Suicide (insured aged less than 25 years)

• Photocopy of birth certificate; and
• Original or certified copy of death certificate; and
• Preliminary coroner's report or medical report specifying cause of death.
   

Hospital and Paramedical Coverage

Hospital Room

• Original statement specifying:
   
  • date of hospitalization
  • length of hospitalization
  • reasons for hospitalization
     

Nursing Care (professional fees only)

• Doctor's order; and
• Photocopy of registered nurse's degree; and
• Nurse's invoice specifying hourly rate and date of care.
   

Chiropractor, Osteopath, Physiotherapist, Occupational Therapist

• Detailled original statement
   

Prescription Drugs

• Original bill
   

Emergency Transport (one-way only)

• Ambulance, taxi and parking: original bill or receipt
• Automobile: number of kilometers in question
   

Rental or Purchase of Crutches, Wheelchair or Walker

• Original bill or receipt
   

Location or Purchase of Orthoses

• Original bill or receipt
• Where the bill is for $100.00 or more: doctor's order
   

First Hearing Aid or Ocular Prosthesis

• Original bill or receipt; and
• Complete medical report since date of accident.
   

Spectacles

• Original bill or receipt
   

Dental Care Coverage

Dental Care

• Original, detailed statement specifying:
   
  • whether the tooth was healthy and natural;
  • the number of the tooth.
     

Transport and Accommodation Coverage

Expenses Incurred by Insured and His/Her Attendant

• Medical certificate or proof of appointment; and
• Number of kilometers (one-way only); and
• Original bill or receipt for meals, accommodation and parking; and
• Date of travel.
   

Educational Costs

Private Tutoring

• Medical report confirming disability of 30 days or more; and
• Photocopy of instructor's degree or diploma; and
• Detailed statement from instructor specifying hourly rate, dates, and type of courses involved.
   

School Transportation

• Date of each trip; and
• Original taxi bill or receipt or number of kilometers in question.
   

Rehabilitation Costs

• Medical report; and
• Original invoice for expenses incurred in career retraining.
   

Compensation for Loss of Summer Job (students aged 17 through 24)

Monthly Benefit

• Proof of school attendance (e.g.: photocopy of transcript); and
• Medical report specifying period of total disability; and
• Date final-stage courses end; and
• Date next school year starts, where applicable.
   

Disappearance of an insured child

• Please contact one of our agents:
   
  • by e-mail; or
  • by telephone, from 8:00 a.m. to 5:00 p.m. Monday through Friday, at 1 877 886-5042.