Instructions for Disability Insurance Claim

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1 Instructions for Disability Insurance Claim Instructions for Claimant 1. Please complete the Claimant's Statement for Group Creditor Disability Insurance. Besuretosign and date all entries. Include your phone number. Complete and sign the authorization at the bottom of the form Date and sign Section 1 and have the physician complete Section 2 of the Attending Physician's Statement of Disability. Retain a copy of the completed claim form for your records. Take the original, completed form to the branch where you have your loan. The branch staff will submit the completed claim to us via courier. If you wish, you may submit the claim documents along with the completed branch statement directly to TD Life Insurance Company, at the address listed below. Branch Instructions Complete the Claim for Group Creditor Disability Insurance. Attach a copy of the application for insurance if available. Be sure to enter the branch transit number, address, telephone number and name of contact person, should it be necessary for the claims department to contact you. 4. Send the completed claim package to: TD Life Insurance Company Richmond Adelaide Centre 120 Adelaide Street West, 2nd Floor Toronto, Ontario M5H 1T1 If you have any questions about completing the form please contact us at

2 Claim for Group Creditor Disability Insurance Statement of Claim (Completed by Branch) Insurer: Prudential Canada Life CT Financial Assurance Branch/Transit Number: Loan Number: Account for direct deposit (if applicable): Please provide details of any other credit insured mortgages, lines of credit or loans held by the claimant at this financial institution. Name of Claimant: (Last Name) (First Name and Initial) Address: (Number) (Street) (City) (Province) (Postal Code) Date of Birth: Date of Disability: If this loan is a refinance of a loan previously insured for disability, please attach a copy of the previous insurance application and complete details below. Open date of pre-refinanced loan Amount of loan prior to refinance Original amortization period of pre-refinanced loan Insurance effective date Date funds advanced Original amount of loan Original amortization period Current balance outstanding Current monthly loan payment Date of last payment Date of regular monthly payment Next renewal date Name, address and telephone number of claimant's employer at time of application, as per Credit Application. Branch Contact: Signature: Title: Date: Telephone Number: ( ) -

3 Claimant's Statement for Group Creditor Disability Insurance Statement of Claim (Completed by Claimant) Section 1 - Claimant's Statement Branch/Transit Number: Loan Number(s): Name of Claimant: Address: (Number) (Last Name) (Street) (First Name and Initial) (City) (Province) (Postal Code) Telephone Number: ( ) - Occupation and Title: Job Description: Date of Birth: 1. When did your health first become affected? 2. From what date has your disability prevented you from working? 3. a) Were you confined to bed? If "", give dates From Dates To Were you confined to your home? If "", give dates c) Were you a patient at a hospital or sanitarium or drug/alcohol rehabilitation centre? If "", give dates 4. Describe your present condition, its cause and history to date. If injured, indicate the nature of the accident. Please also advise when and where the accident occurred and how it came about. 5. a) Does your health completely prevent you from working now? If not working, when do you anticipate returning to: 1) your own job? 2) another job? 6. c) If now working 1) Briefly state your duties. 2) When did you return to work? a) Name and address of Family Physician. Number of s: Names of all Physicians who have attended you during this disability. Name Address From Dates To This claim form can be used for otherwise valid claims under discontinued policies. (continued) Section 2 - Disability Claim Authorization Branch and Account Number: Insurer: Prudential Canada Life CT Financial Assurance (may be completed by the administrator) Claimant's authorization: I hereby authorize and request any physician, hospital, clinic, individual, law enforcement or government organization, insurance company, worker's compensation body, current or former employer, or other entity that has any personal and medical records, information or knowledge in regard to the claimant, to release and provide full details (including furnishing copies) of all available personal and medical information records and knowledge, including prior medical history, toxicological or pathological findings which they may possess to the above noted insurer in regard to this claim, its authorized administrator, TD Life Insurance Company, its re-insurers or their respective agents. Thisinformationistobeusedintheevaluationofaninsuranceclaimandforpurposesrelatingtosuchclaim.Thisconsentshallbe valid during the continuation of such claim. I also authorize my insurer, its authorized administrator, TD Life, its reinsurers and their respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. (Print Name) Date Witness Claimant's Signature A photocopy/fax of this authorization shall be as valid as the original.

4 7. a) What is your level of education in Canada? If educated outside Canada, what is the Canadian equivalent? c) Have you attended any trade schools or received other special training? d) List and give details of all previous occupations. e) What are your hobbies and/or other special interests? f) In your opinion, how do your limitations and symptoms prevent you from performing your usual job duties? g) (i) Do you expect to return to your previous occupation? (ii) Do you expect to return to any occupation? h) Have you discussed returning to work or rehabilitation with your doctor? If "", what is his/her opinion? i) Have you contacted Employment Insurance Canada Rehabilitation Services on the possibilities of vocational retraining? If yes, what is the name and address of the counselor in charge of your case, and what vocational plans have been made? Declaration: I declare that the statements made are true, complete and correctly recorded. I understand that concealment, misrepresentation or false declaration concerning this statement could cause my insurance to be void. Signature of Claimant: Date:

5 Attending Physician's Statement of Disability Section 1 - Patient's Authorization Patient's Name (Please Print) I hereby authorize the release of any information requested in respect of this claim, to my insurer and its authorized claims administrator, TD Life Insurance Company. Date Signature of Patient The patient is responsible for the securing of this form and any charge which may be made for its completion. Section 2 - To Physicians - Please note This form has been specifically designed to reduce the physician's administrative workload. Please complete the sections which relate to your patient and stroke out non-applicable areas. In order to help the claimant, it is essential to provide sufficient details of history, investigation, findings and treatment. 1. History a) General Information Height Weight Age When did symptoms first appear, or accident happen? c) Date total disability commenced? d) Has patient ever had same or similar condition? If "", state when and describe. Unknown e) Is condition due to injury or sickness arising out of patient's employment? Unknown f) Name and address of family physician if other than yourself Number of years attended g) Names of other treating physicians 2. Diagnosis a) Date of Diagnosis Primary Diagnosis (including any complications) Secondary Diagnosis (if applicable) Objective findings (including results of current X-rays, ECGs or any other special tests). Please attach copies of any test results. (continued) If you wish, you may mail this form to the administrator at the address below: TD Life Insurance Company, Richmond Adelaide Centre, 120 Adelaide Street West, 2nd Floor Toronto, Ontario M5H 1T1. Tel :

6 3. Treatment a) Any hospitalizations? If "", please provide details Date of first visit c) Date of latest visit d) Frequency Weekly ly Other (specify) e) Is patient following recommended treatment program? 4. Type of Treatment a) Describe therapy and projected duration of treatment program. Date and description of surgery (if applicable) 5. Prognosis a) Do you think that your patient will be able to return to work? If "", indicate when If unable to return to prior occupation, is your patient able to return to modified work? If "", indicate when Declaration: These statements are true and complete to the best of my knowledge and belief. Physician's Signature: Date: Specialty: Name: Telephone Number: ( ) - Address: Fax Number: ( ) -

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