Chubb Insurance Forms

Insurance Plan

  • Please be advised, this Accident and Sickness Insurance Plan, underwritten by Chubb Life insurance company (Canada), is only in effect until the end of 2021. These forms should only be used to file claims for expenses incurred before December 31, 2021 or for ongoing expenses that continued into the new year.
  • Forms and contact information for expenses incurred as of January 1, 2022, are available here and should be submitted to the current plan provider, Crawford & Company.

Questions about your individual coverage or a claim under this expired insurance plan should be directed to Chubb.

Chubb Life Insurance Company of Canada

2500 - 199 Bay Street
P.O. Box 139, Commerce Court Postal Station
Toronto, ON M5L 1E2
Medical claims:: 1-866-356-5662
Income replacement claims: 1-877-772-7797
General email:

Medical / Paramedical Claim Forms

  • Accidental Dental
    Use this form to claim reimbursement for dental expenses incurred when treatment is required as a result of an accident. If the accident occurs while on contract, the reimbursement is no more than 80% per cent to a maximum of $2,500. If you are eligible for off-contract coverage, the reimbursement rate is 50% per cent. Note that this form must accompany a standard dental claim form completed by your dentist.
  • Health and Wellness
    This form is applicable to a variety of miscellaneous services and expenses as described on Page 2 of the form. There is an annual allowance of $100 for all members, whether you are on or off contract.
  • Medical / Paramedical Claimant Statement
    Use this claim form for expenses related to physical therapies, medical expenses and alternative medicine. Note that maximums for physical therapies are different for all members: either $600 or $1,200 per treatment depending on your contract. Also, medical expenses have a collective maximum of $5,000 and alternative medicines have a collective maximum of $750. Supporting documentation may be required.
  • Practitioner Statement
    This form may be required depending on your claim situation and should accompany your Medical/Paramedical Claim Form.

Income Replacement Benefit Claim Forms

  • Attending Physician Statement
    This form needs to accompany your Income Replacement Benefits Claim Form. It must be completed by your physician.
  • Claimant Statement
    Use this form to apply for income replacement if you need to drop out of a current or upcoming contract due to illness or injury. If you are working, you are insured for 60% per cent of your contractual weekly fee to a maximum of $1,500 per week for up to 52 weeks. Additional supporting documentation is required.

Insurance Policy Maximums and Customary Fees

  • Policy Maximums
    Insurance plan provider chart identifying policy benefit, eligibility, reimbursement, policy maximums and occurrence.
  • Reasonable and Customary Fee Guide
    Reasonable and Customary Charges for Paramedical Services correspond to the maximum acceptable amounts as established by the insurance plan provider, for certain services, according to their average cost in any given region.