Insured: Bright Erhaboh
Student No: 22080989 Group #: 5229
Start Date: Sep 01, 2024 Policy # 10585316UM
End Date: Aug 31, 2025
Organization: Sault College
PLEASE PRINT CLEARLY
GuardMe Policy Number: 10585316UM Coverage Start Date: Sep 01, 2024
Organization or School Name: Sault College Coverage End Date: Aug 31, 2025
Name of Insured/Patient: Bright Erhaboh Date of Birth: Jun 24, 1981
Payee Name: Mailing Address:
City: Province/State/Region: Zip/Postal Code:
Tel: Fax: Email:
Cheque (Make cheque payable to) Same as above Different Address:
Direct Deposit (Attach Void Cheque). Email address required:
1. Do you have other insurance which covers medical expenses in Canada? NO or YES If yes, please provide details:
2. BC Students, if your claim is for services provided in a Hospital, please attach your valid study (or work) permit (if applicable).
3. Were you hurt in an accident? NO or YES Tell us what happened, when and where the accident occurred, and if a vehicle or
workplace was involved:
4. Tell us WHEN and WHY you received treatment (below). Please attach original bills and receipts with this Claim Form.
Date of onset of sickness Date of Service Cost/Currency Describe the injury or illness that required
or injury (yyyy/mm/dd) (yyyy/mm/dd) the treatment (or Diagnosis)
FOR DIRECT BILLING BY MEDICAL PROVIDERS ONLY
For prompt reimbursement as detailed below, FAX this signed form to GuardMe
Rx Given X-ray Ordered Lab Work Ordered Other/Details
Is this emergency treatment, medically necessary to identify and/or treat a new, acute, unexpected sickness? NO or YES
______________________________________________________________________________________________________________________________
If you answer YES, we will reimburse eligible expenses to you directly.
If you answer NO, have the insured pay for this visit. Please call the below number if you have any questions.
_____________________________________________________ ________________________________________________________________
Medical Provider's Name PRINT Date Medical Provider’s Signature (only required for direct payment)
I, the undersigned, declare that all the information I have provided in this Claim Form is true and complete. I acknowledge
ATTACH ALL BILLS AND MAIL TO: receipt of Travel Healthcare Insurance Solutions Inc. / GuardMe‘s privacy statement. I authorize any hospital, physician,
GuardMe Claims other medical provider or insurer to provide by any secure means my medical record to Travel Healthcare Insurance
80 Allstate Parkway Solutions Inc. / GuardMe and its insurers for the purpose of administering claims. All information is to be held in
Markham, Ontario L3R 6H3 complete confidentiality and is not to be released to any party apart from those listed above. Use of my email address will
be restricted to insurance inquiries unless I initiate email contact. A photocopy or facsimile transmission of this Claim Form
Tel: +1-888-756-8428 or +1-905-752-6200
is as valid as the original. I assign my right to payment to the party indicated above.
www.guard.me
Medical Providers only Fax to:
+1-866-329-6948 or +1-905-752-6235
Insured/Legal Guardian (Signature) Date
GM CMDM Claim 12/2024 This form may be copied Underwritten by: Old Republic Insurance Company of Canada
