17-03 Annex A Appendix 1 - Claimant's Statement

Policy number: SRG 913 37 19

Claimant’s Surname:

Claimant given name: 

Address (Street & No):

Apt./Unit no:

Telephone no:

City/Town: 

Povince: 

Postal Code:

Date of birth:

Sex:

1. Date of Accident:
   Date of Initial Medical attention:
2. Full details of Accident:
3. What injuries were sustained?
4. Name and address of family physician:
5. Name and address of witnesses to this accident:
6. Name and address of Surgeons or Specialists who provided treatment regarding this accident:

PERSONAL INFORMATION NOTICE: I understand that the information provided by me on this claim form and otherwise in respect of my claim, is required by American Assurance Company, its re-insurers and authorized administrators (“the insurer”) to assess my entitlement to benefits, including but not limited to determining if coverage is in effect, investigating the applicability of exclusions and coordinating coverage with other insurers. For these purposes, the insurer will also consult its existing insurance files about me, collect additional information about and from me, and where required, collect information from and exchange information with, third parties. CERTIFICATION: The statements I provide in completing this claim form and otherwise in respect of my claims are true and complete to the best of my knowledge and belief. In the event of a false or misleading statement in the making of this claim, coverage, coverage can be cancelled, payment of benefits denied and past claims payments recovered. I agree to refund to the Insurer, the amount of say payments made in the event that such amounts should not have been paid in respect of my claim. AUTHORIZATION: I authorize for a period of not less than twelve and not more than twenty-four months from the date hereof, say physician, practitioner, health care provider , hospital care institution, medical organization, clinic and say other medical or medically related facility, any insurance company, workers compensation board or similar plan or organization, benefit plan administrator, federal, territorial or provincial government department, or say other corporation or organization, institution or association (including obtaining information from the group policyholder or my employer) to release and exchange with American Home Assurance Company, or representatives thereof, all personal health information, benefit payment, employment or financial information about me or any other information or records about me in its possession that is requested while administering my claim. 

I agree that a reproduction of this authorization shall be as valid as the original

Date:

Claimant’s signature: