CI eClaims form

Please complete the following information and submit the form. We will contact you shortly to provide you with claim requirements.

* Mandatory fields

Insured information

Policy number:*

Policy number is required

Insured first name:*

First name is required Must be minimum 2 characters

Insured last name:*

Last name is required Must be minimum 2 characters

Insured address:*

Your address is required

Date of birth:

Date of diagnosis:

Diagnosis*

Diagnosis is required

Your information

First name:*

Your first name is required

Last name:*

Your last name is required

Your relationship to insured:*

Relationship is required Must be minimum 3 characters

Your phone number:*

Phone is required Invalid format

Extension:

Invalid extention format

Your email address:

Email is required. Invalid format

Please send claim forms by:*

Mail -- to insured's address above

Email -- To my email address above

Please choose how to send

Questions? Contact us at 1-855-806-5057 (8:30 a.m. – 6:00 p.m.) or [email protected]