VISITORS TO CANADA MEDICAL INSURANCE

Instructions: TO REPORT A CLAIM, call 1-877-882-2957 toll-free USA and Canada. If unable to use the toll-free number, call collect to Canada:
+1 519-251-7856. TO ENQUIRE ABOUT THE STATUS OF YOUR CLAIM, call 1-866-228-6386 from 8:00AM to 8:00PM ET.

a) Complete for any applicant age 60 to 85 who is applying for the Stable Chronic Condition Option.
b) Complete for all applicants age 86 or over. c) Fax to 1-866-255-0155 or mail to 21st Century within 3 business days of applying.

No premium will be refunded if a claim has been reported under this policy.
A $25 Administration Fee will be applied to all refunds. Refer to policy for full details.
Must be completed in full by Insured or Sponsor.