NAME OF PHYSICIAN

SIGNATURE OF PHYSICIAN DATE

TELEPHONE( )

D M Y

PHYSICIAN’S STAMP

PATIENT’S NAME

1. PRIMARY DIAGNOSIS (CONDITION WHICH IS THE CAUSE OF THE CLAIM)

2. IS THIS A NEW CONDITION?

3. DATE OF CONSULTATION FOR THE CURRENT ONSET OF THIS CONDITION?

IF YES, PLEASE PROVIDE ALL DATES

IF YES, PLEASE PROVIDE DATES 12. HOW DOES THE ABOVE CONDITION AFFECT THE PATIENT’S ABILITY TO TRAVEL?

EXPLAIN:

YES NO

7. WAS THE MEDICATION ALTERED IN THE PAST 12 MONTHS? YES NO

4. HAS THE PATIENT RECEIVED TREATMENT OR ADVICE FOR THISCONDITION (OR RELATED CONDITION) IN THE LAST YEAR?

8. IF THE PATIENT WAS REFERRED TO YOU, PROVIDE NAME AND PHONE NUMBER OF REFERRING FAMILY PHYSICIAN

YES NO

9a. HAS THE PATIENT BEEN HOSPITALIZED FOR THIS CONDITION(OR RELATED CONDITION) IN THE PAST 12 MONTHS?

YES NO

10. WAS THE CANCELLATION OR INTERUPTION OF THE TRIPDUE TO PREGNANCY?

IF YES, WHAT WAS THE EXPECTED DATE OFDELIVERY?

YES NO

11a. IF THE PATIENT WAS THE INTENDED TRAVELLER: DID YOU ADVISE THE PATIENT NOT TO TRAVEL?

YES NO

11b.ON WHAT DATE WAS THIS CONDITIONSTABLE ENOUGH TO PERMIT THE PATIENTOR FAMILY MEMBER TO TRAVEL?

9b. WERE FOLLOW UP TREATMENTS REQUIRED? YES NO

IF NO, ON WHICH DATE WAS THIS CONDITION FIRST DIAGNOSED?

DATE OF BIRTH

D M Y

D M Y

D M Y

6. DATE MEDICATION FIRST PRESCRIBED?

D

D

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Y

Y

D

D

M

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Y

D

D

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Y

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D

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IF YES, PLEASE PROVIDE DATESD

D

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IF YES, ON WHAT DATE?D M Y

Y

D

D

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Y

Y

IF YES, PLEASE PROVIDE DATESD

D

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Y

D

D

M

M

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Y

D M Y

D M YD M Y

NAME OF REFERRING FAMILY PHYSICIAN TELEPHONE

( )

AUTHORIZATION AND RELEASE This section must be completed in full by all claimants

CLAIMANT’S STATEMENT This section must be completed if claiming Trip Cancellation, Interruption or any Travel Delay or other travel related expenses

IF CLAIMING MEDICAL EXPENSES

MR/MRSMISS/MS INSURED LAST NAME

GOVERNMENT HEALTH INSURANCE PLAN NUMBER

NO./STREET/APT.

PROVINCE POSTAL CODE HOME TEL. BUSINESS TEL.

CITY

FIRST NAME BIRTH DATE

VERSION CODE

POLICY/CONFIRMATIONNUMBER

IF CLAIMING MEDICAL EXPENSES

MR/MRSMISS/MS INSURED LAST NAME

GOVERNMENT HEALTH INSURANCE PLAN NUMBER

FIRST NAME BIRTH DATE

VERSION CODE

POLICY/CONFIRMATIONNUMBER

1)

2)

D M

M

Y

YD

TRAVELLING COMPANION MR/MRS/MISS/MS LAST NAME FIRST NAME

POLICY/CONFIRMATIONNUMBER

ADDRESS FOR CORRESPONDENCE OR CLAIM PAYMENTS

( ) ( )

DATE OF DEPARTURE

NAME OF PERSON WHO COMPLETED THIS FORM RELATIONSHIP TO CLAIMANT

SIGNATURE OF INSURED / INSURED’S GUARDIAN DATE OF SIGNATURE

DATE CLAIM SUBMITTED

DEPARTURE POINT DESTINATION

DATE OF RETURN DATE OF CAUSE OF CLAIM

SIGNATURE OF CLAIMANT

D M

M M

Y

Y YD D

D M Y

By signing below, I hereby consent to, authorize and direct that Reliable Life InsuranceCompany or its representative may recover from my Government Health Insurance Plan(GHIP) and/or any other Health Insurance carriers or entities, payments which were madeto others on my behalf for out-of-province health services.Furthermore, I agree that, pursuant to any applicable federal, provincial or territorial health insurance legislation as it pertains to freedom of information and protection ofprivacy, I hereby:1. Direct and authorize the Government Health Insurance Plan (GHIP) to make payment

in respect of my claim for out-of-province health services to Reliable Life Insurance Company or its representative, and upon such payment, I hereby release GHIP from any further claim or cause of action in connection with such claim; and

2. Consent to and authorize GHIP to directly or indirectly collect information contained in the claim and source documents pursuant to applicable provincial legislation; and

3. Consent to the disclosure by GHIP to Reliable Life Insurance Company or its representative of such personal information as may be necessarily required to process my claim for out-of-province health services, including the details of any payment previously made directly to me or on my behalf.

Authorization to Physicians, Hospitals, other Health Care Practitioners, Medical Care Facilities, Insurance Carriers, any other Person who has attended or examinedme and Other Sources:I hereby authorize and direct that you release to Reliable Life Insurance Company or its representative, Pottruff & Smith, any and all information you have regarding me, whileunder your professional care, including my medical history, any illness, injury, consultation,medicines or treatment and copies of all hospital and medical records. This authorization will

permit Reliable Life Insurance Company to use the disclosed information for the purpose of determining my eligibility for coverage under my travel insurance policy, assessinginsurance risks, managing my claim and negotiating or settling payments to third parties.This authorization will permit Reliable Life Insurance Company's representative, Pottruff &Smith, to use the disclosed information for the purpose of determining my eligibility forcoverage under my travel insurance policy and processing my claim. I hereby assign toReliable Life Insurance Company any benefits obtained from other sources for lossescovered under this policy. I also direct these sources to forward payment to Reliable LifeInsurance Company for my claims submitted by Reliable Life Insurance Company withregard to these losses. A photocopy, facsimile or electronic copy of this authorization isacceptable. This authorization will also permit Reliable Life Insurance Company to releaseand share information with any or all parties noted above.I certify that the statements and particulars given herein together with those on any accompanying documents are complete, true and correct to the best of my knowledge.I understand the reasons for which I have been asked to consent to the disclosure of my personal information and am aware of the risks or benefits of consenting, or refusingto consent, to the disclosure. I understand that I may revoke this consent at any timeby written notification to Reliable Life and/or its representative Pottruff & Smith. I alsounderstand that the making of false or fraudulent statements in connection with a claim forbenefits may render the certificate of insurance or the policy void.

D M Y

TRIP CANCELLATION/INTERRUPTION/DISRUPTION/TRAVEL DELAYDESCRIBE IN DETAIL THE CAUSE AND CIRCUMSTANCES OF THE TRIP CANCELLATION OR TRIP INTERRUPTION OR TRIP DISRUPTION OR TRAVEL DELAY

ON WHAT DATE WAS THE TRIP BOOKEDWITH AIRMILES®?

DATE OF DEPARTURE

DATE OF RETURNON WHAT DATE WAS THE TRIP CANCELLEDWITH AIRMILES®?

NAME OF SICK/ INJURED/DECEASED PERSON**The Physician's statement must be completed by the attending Physician of the sick/ injured/deceased person

NAME OF THE TRAVEL SPECIALIST WHO CANCELLED THE TRIP

BIRTH DATE DATE OF SICKNESSINJURY OR DEATH

RELATIONSHIP TO THE CLAIMANT

ADDRESS OF SICK/ INJURED/DECEASED PERSON (IF OTHER THAN CLAIMANT) CITY POSTAL CODEPROVINCE TELEPHONE( )

TELEPHONE( )

D D

D

D D

M M

M

M M

M

Y

Y Y

Y

Y

YD

PAGE 1

1b

DATE OF CONSENT

D M YEND DATE OF CONSENT: 12 MONTHS FROM DATE OF SIGNATURE

PHYSICIAN’S STATEMENT FOR TRIP CANCELLATION OR TRIP INTERRUPTION CLAIMSTHIS SECTION MUST BE COMPLETED BY THE ATTENDING PHYSICIAN

CLAIMANT INFORMATION This section must be completed in full by all claimants

DID/WILL YOU RECEIVE ANY REFUNDSFROM ANY OTHER SOURCE?

AMOUNTNO YES

NOTE: THE CLAIMANT IS RESPONSIBLE FOR THE COST OF COMPLETION OF THIS MEDICAL CERTIFICATE PSRL 401 EO4

IF YES, PLEASE PROVIDE NAMES

5. IS THE PATIENT PRESCRIBED MEDICATION(S) FOR THIS CONDITION (OR RELATED CONDITION)?

YES NO

CLAIM FORMCLAIMS WILL NOT BE PROCESSED UNTIL THEREQUIRED SECTIONS HAVE BEEN FULLY COMPLETEDAND SUBMITTED WITH REQUIRED DOCUMENTATION

SUBMIT CLAIM TO:AIR MILES® TRAVEL INSURANCEc/o POTTRUFF & SMITH TRAVEL INSURANCE BROKERS INC.8001 Weston Road, Suite 300Woodbridge, Ontario L4L 9C8Telephone: 1-866-298-6581 Fax: 905-856-1539

IN QUÉBECASSURANCE-VOYAGE AIR MILESmd

a/s POTTRUFF & SMITH COURTIERS d’ASSURANCE VOYAGE INC.83, rue Turgeon, Bureau 300Ste-Thérèse, Québec J7E 3H7Telephone: 1-866-298-6581 Fax: 450-434-5543

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AIRMILES/REWARD MILESCASH CLAIMED

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MEDICAL CLAIM SECTIONTHE CLAIMANT MUST COMPLETE THIS SECTION IN FULL

CLAIMANT’S STATEMENT This section must be completed if claiming medical expenses

COVERAGE WITH OTHER INSURERS AND OTHER SOURCES This section must be completed in full by all claimants

RESIDENTS OF: BRITISH COLUMBIA THIS SECTION MUST BE COMPLETED PRIOR TO ANY MEDICAL CLAIM PAYMENTS

AUTHORIZATION TO PROVIDE MEDICAL INFORMATION AND ASSIGNMENT OF PAYMENT TO INSURED PERSONOR BENEFICIARY UNDER THE MEDICARE PROTECTION ACT OR HOSPITAL INSURANCE ACT

EXPENSES CANNOT BE PAID UNLES THESE SECTIONS HAVE BEEN COMPLETED IN FULL AND RECEIVED BY THE COMPANY.

GOVERNMENT HEALTH INSURANCE PLAN SECTION (GHIP) AUTHORIZATION & RELEASE

IMPORTANT• BC residents must complete GHIP Authorization and Release section below. • Saskatchewan and Québec residents must contact the Claims Customer Service at 1-866-298-6581 to obtain the appropriate

GHIP Authorization and Release form. • All claimants must complete the Authorization and Release section on the opposite side.

DATED this

BETWEEN of the first part hereinafter referred to as the Assignor

day of, 20

SIGNATURE OFASSIGNOR

ASSIGNMENT:EFFECTIVE FROM TO:

PERSONALHEALTHCARD NO.

WITNESSSIGNATURE OCCUPATION

ADDRESS

CITY PROVINCE POSTALCODE

TELEPHONE ( )

AND RELIABLE LIFE INSURANCE COMPANY C/O POTTRUFF & SMITH TRAVEL INSURANCE BROKERS INC. of the second part, hereinafter referred to as the Assignee8001 WESTON RD, STE. 300, WOODBRIDGE, ONTARIO L4L 9C8

AND HER MAJESTY THE QUEEN IN THE RIGHT OF THE PROVINCE OF hereinafter referred to as the MinisterBRITISH COLUMBIA AS REPRESENTED BY THE MINISTER OF HEALTH

WHEREAS the Assignor is a person eligible for insured services or benefits or both under the Province of British Columbia’s Medicare Protection Act or Hospital Insurance Act or both, and as such may receive payment forthe above services from the Minister.

And WHEREAS the Assignor is under a covenant or obligation under a contract with the Assignee to remit to the Assignee all such payments received for medical services from the Minister.

NOW WITNESSETH THAT in consideration of the said obligation to the Assignee the Assignor hereby assigns unto the Assignee all sums of money that shall be owing to the Assignor by the Minister for the above notedcontract. The Minister is hereby authorized to pay all such sums directly to the Assignee at the address aforesaid, or at any address the Assignee may from time to time designate, with payment of any such sum to besufficient discharge to the Minister of and from any indebtedness in that amount to the Assignor, his heirs, executors, or administrators.

I HEREBY CONSENT TO AND AUTHORIZE THE MINISTRY OF HEALTH TO FURNISH ANY REPRESENTATIVE OF RELIABLE LIFE INSURANCE COMPANY ANY AND ALL RECORDS AND INFORMATION IN THE MINISTRYOF HEALTH’S POSSESSION REGARDING CLAIMS FOR MEDICAL SERVICES INCURRED WHILE I HAD INSURANCE COVERAGE FOR THE ASSIGNMENT PERIOD INCLUDING MEDICAL HISTORY AND PHYSICALCONDITION BOTH PRIOR AND SUBSEQUENT TO RECEIPT OF MEDICAL SERVICES, REGARDLESS OF LAPSED TIME AND BEARING IN ANY WAY ON THE SERVICES RECEIVED DURING THE ABOVE TIME PERIOD.

DESCRIBE IN DETAIL THE CAUSE AND CIRCUMSTANCES OF THE SICKNESS OR INJURY

DATE OF INJURY OR SICKNESS LOCATION OF SICKNESSOR INJURY

CITY COUNTRY

WERE YOUHOSPITALIZED?

YES NO ADMISSIONDATE

DISCHARGEDATE

DATE YOU RETURNEDTO CANADA

DID YOU CONTACT THE ASSISTANCE PROVIDER (24 HOUR SERVICE) AT THE TIME OF THE SICKNESS OR INJURY? NO ASSISTANCEFILE NO.YES

AMOUNTCLAIMED CURRENCY HAS THE BILL

BEEN PAID?NO YES IN

FULLINPART

AMOUNTPAID

GOVERNMENT HEALTHINSURANCE PLAN NUMBER

FULL NAME AS REGISTERED WITHGOVERNMENT HEALTH INSURANCE PLAN

VERSION CODE(ONTARIO RESIDENTS)

NAME OF PARENT OR GUARDIANIF CLAIMANT UNDER AGE 16

NAME OF YOUR SPOUSE (IF APPLICABLE)

FULL NAME OF YOUR USUAL PHYSICIAN IN YOUR PROVINCE OF RESIDENCE

NO./STREET/SUITE NO.

CITY PROV. POSTALCODE TEL. ( )

WERE YOU HOSPITALIZED FOR THIS SICKNESS/INJURY (OR RELATED CONDITION(S)) IN THE LAST 12 MONTHSPRIOR TO THE DEPARTURE DATE SHOWN IN THE POLICY APPLICATION?

CLAIMANT’S (OR PARENT’S)OCCUPATION

NAME OF YOUREMPLOYER

CITY

NAME OF SPOUSE’S EMPLOYER

CITY

YES NO

NO

NO

GROUPPOLICY NO.

POLICY NO.

NAME OFCOVERED PERSON

CARD TYPEBANK

NAME AND ADDRESS OFINSURANCE COMPANY/BROKER

IDENTIFICATIONNO.

NAME OFINS. CO.

NAME OFCARDHOLDERYES

YES

EMPLOYEE GROUP BENEFITS PLAN OR RETIRED EMPLOYEE GROUP BENEFITS PLAN

ON THE DATE OF THE SICKNESS OR INJURY, INDICATE BELOW IF YOU (OR YOUR SPOUSE) WERE COVERED FOR OUT OF PROVINCE MEDICAL EXPENSES:

CREDIT CARD COVERAGE (IE: GOLD OR OTHER)

ANY OTHER COVERAGE (IE: UNION, PENSIONER, PRIVATE OR OTHER POLICY OR OTHER SOURCES OF RECOVERY) UNDER WHICH YOU ARE ENTITLED TO BENEFITS

FULL TIMEEMPLOYMENT

SELFEMPLOYED

PART TIMEEMPLOYMENT

ADDRESS -NO./STREET/SUITE NO.

POSTAL CODE

POSTAL CODE

PROVINCE

ADDRESS -NO./STREET/SUITE NO.

PROVINCE

STUDENT RETIRED UNEMPLOYED OTHER

TEL. ( )

( )TEL.

YES NO

D

D M Y D M Y D M Y

M Y

D M Y D M Y

PAGE 2

2a

AMOUNTCLAIMED/REFUNDEDHAVE YOU SUBMITTED THIS CLAIM TO YOUR GOVERNMENT HEALTH INSURANCE PLAN? NO YES

AMOUNTCLAIMED/REFUNDEDHAVE YOU SUBMITTED THIS CLAIM TO ANY OTHER PLAN? NO YES

NAME AND ADDRESSOF COMPANYOTHER SOURCES

CREDIT CARD NO.(FIRST 6 DIGITS)

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