Travel Claim Request Form

Please enter your personal and travel claim information into the form below. Once complete, a representative from Medavie Blue Cross will contact you with the appropriate forms to be completed.

Last Name * First Last
Email Address *
Student Number
*
Policy Number *
Province of Residence *
Are you an International Student?
Yes
If you are an International Student, please enter your Home Country
Provincial Healthcare Card Number
If you are an international student (without provincial healthcare), enter your insurance company name and policy number
Date of Departure * / MM / DD YYYY
Date of Return * / MM / DD YYYY
Location of Services Rendered (City, Country) *
Diagnosis/Symptoms/Reason for Consultation *
What was the total amount paid for services? * $ . Dollars Cents
What is the currency of the total amount paid for services?
*
Were these expenses incurred due to an accident? *
Yes No
If yes, please explain
Additional information and/or comments