Penfield - New Claim

Submit Travel Medical Claim

Initiate your claim by completing each step.

Patient

Emergency

Expenses

Insurance

Uploads

Patient Profile

First Name *

Last Name *

Date of Birth *

Gender *

Telephone Number *

Email Address *

Confirm Email Address *

Street Address Line 1 *

Suite / Apt (Opt)

City *

Province/State *

Postal / Zip Code *

Country *

Policy Holder *

I am the policy holder I am not the policy holder

Emergency Details

Date of Emergency *

Policy Number *

Nature of Medical Emergency *

Type of Services Provided (Select all that apply)

Doctor Appointment Walk-in Clinic / Urgent Care Clinic Emergency Room Visit Hospital Admission Dentist Other

Family Doctor in Home Country (Name, Phone, Fax, Email, Location) *

Expenses & Reimbursement

Did you incur out-of-pocket medical expenses? *

YES, I incurred out-of-pocket expenses NO, I did not incur expenses

Medical Expense List (Detail your out-of-pocket bills, dates, and amounts) *

Please enter individual line items for up to 5 medical expenses.

Date of Service

Description of Service

Amount Paid ($)

Total Amount Paid (Out-of-Pocket) *

Total out-of-pocket amount paid by patient. Any unpaid outstanding invoices will be billed directly to Penfield.

Who is receiving the reimbursed funds? *

Policy Holder Other Authorized Recipient

How would you like eligible funds to be sent? *

Cheque E-transfer Wire Transfer Direct Provider Payment (Provider is to be paid directly for outstanding invoices)

Mailing Address for Cheque *

Interac E-transfer Email Address *

Bank Name *

Transit / Branch Number *

Account Number *

SWIFT Code / IBAN *

Direct Settlement Selected: Penfield will arrange direct payment with the healthcare provider or medical facility based on submitted unpaid invoices.

Coordination of Benefits

Are you entitled to benefits under any other insurance plan? *

Yes, I have other coverage No other coverage

Do you have a credit card with travel insurance? *

Yes No

Trip Timeline

Departure Date to Destination *

Return to Home Country *

Return date unknown

Document Attachments

Upload supporting documents for your claim. Maximum file size is 10MB per file (Supported formats: PDF, PNG, JPG, DOCX).

Proof of Travel (Itinerary, boarding pass, or passport stamp) (Max 10MB)

Accepted formats: PDF, JPG, PNG, DOCX (Max 10MB)

Attach Medical Documents (doctor's notes, medical records, requisitions, test results, etc.) (Max 10MB per file)

Accepted formats: PDF, JPG, PNG, DOCX (Max 10MB per file)

Invoices, Receipts, or Credit Card Statements (Max 10MB per file)

Accepted formats: PDF, JPG, PNG, DOCX (Max 10MB per file)

Authorization & Consent

I declare that all details in this claim form are true, correct, and complete to the best of my knowledge, and I authorize Penfield to process my claim. *

E-Signature Name (Type Full Legal Name) *

Our Assistance team is available 24 hours a day, 7 days a week. Please keep us updated on any changes to your condition or if you require further assistance.

Please be aware that all claims are subject to a routine verification of coverage. Your claim will be reviewed to ensure that policy benefits, limitations, and eligibility requirements are respected.

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