docQuestionnaire sur les exclusions protection
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SUPPLEMENTAL STATEMENT OF HEALTH INDIVIDUAL
If Yes, please provide details including date, symptoms/diagnosis, duration and names of doctors.
pre-authorized debit
I/we have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to
receive reimbursement for any PAD that is not authorized or is not consistent...
MISC 300 - AA Stuffer Generic.indd
Le symbole et le nom Croix Bleue sont des marques déposées de l’Association canadienne des Croix Bleue, utilisées sous licence par Croix Bleue Medavie, titulaire de licence indépendant de l’Associa...
1-800-565-0065 Fax: 1-506-867-4651
q Quarterly Billing: four times a year (do not complete financial information below.)
OR
q Monthly Pre-authorized Debit (PAD) (Please complete the Pre-authorized Debit (PAD) plan
agreement b...
commande de formulaires order form
Veuillez retourner ce formulaire au / Send this form to
550, rue Sherbrooke Ouest, bureau L-15, Montréal (Québec) H3A 6T6, téléphone : 514-286-7778 / 1-877-286-7778 • télécopieur : 514-286-8439
Le...
MANAGING CHRONIC DISEASE CLAIM FORM
I understand that the personal information provided herein, as well as any other personal information currently held or collected in the future by my Blue Cross plan may be collected, used, or disc...
STATEMENT OF HEALTH FOR DEPENDENTS
I, the undersigned, declare the answers to the above questions are complete and accurate and form part of an application for coverage
with Blue Cross Life Insurance Company of Canada (Blue Cross Li...
