In-Ganada Claim Form ffi studyinsured"

INSTRUCTIONS
. Att claims must be reported to lntrepid 24/7" withln 30 days of occurrence.
. Written proof of claim must be submitted to ,ntrepid 2417" within 90 days of occurrence.
. You are responsibte for att fees charged for any supporting documentation.
. Failure to comptete and sign this form in its entirety or submit supporting documentation wil.t detay claim processing.

. Complete att sections and ensure this form is signed before submitting to lntrepid 24/7" with a[[ invoices, physician and medical reports detailing
treatment and treatment dates, and prescription pharmacy receipts. Keep copies for your records.
. Ctaimants must attach a copy of the emergency room report and att hospital records if treatment was received at a hospita[.
SECTION A: CLAIMANT / INSURED
INSURED PERSON

Anas Mokhammad Nasrul )410311981

Last Name Firet Name Dat€ of Birth (DD/MM/YYYY)

EI uate D Femate fl Non-binary D undiscLosed ndonesia 27t08t2018

Country of Origin Arrival Date in Canada (DD/MM/YYYY)

MSS 301 142649 McGill University c1/09/2018

Poticv Number Group Number lD Number EducationaI lnstitution Enro[Lment Date (DD/MMIYYYY)

INSURED PERSON'S ADDRESS Tt{ CA]TADA

CLAIMANT (IF DIFFERENT FROM INSURED PERSON)

TREATING PHYSICIAN FOR THIS CLAIM

IT{SURED PERSON'S FAMILY PHYSICTAN TN COUNTRY OF ORIGIT{ (TF AVAILAELE)

SECTION B: OTHER INSURANCE CoVERAGE

Does the insured person currently have provincial or government coverage of any kind? [ Yes E tto

ls the insured person covered by another medicat or travet insurance poticy (inctuding coverage through a spouse, parent, or guardian?) D ves EI r.ro
provide detaits of other insurance coverage:

Fut[ Name of Poticyhotder lnsurance ComDanv

Policy/Ptan Number lDlCertificate Number Emptoyer croup Number Employer Name Emptoyer Phone
ril ennlieahlp\ lif rEnlicahle) lif aoolicabte)
 SECTION C: CLAIM INFORMATIoN
Description of insured's sickness or injury (if this space is insufficient, additional information can be attached):

is bleeding and pain in mouth and jaw, to be advised tooth extraction.

Date symptoms first appeared or injury occurred (DD/MM/YY):

Has the insured person ever been treated for this, or a simitar or related, condition before? fl Yes El ruo
Date insured first saw a physician for this, or a simitar or re[ated, condition (DD/MM/YY):

Ptease provide atl dates of treatment and [ist atl medications taken for this, or a similar or related, condition before the effective date of the poticy:

Treatment Date (DD/MM/YY) Medication

29t05t2020 500 mg caps Amoxcicillin

SEGTION D: EXPENSES CLAIMED

Reason for visiting Date of Service
Name of Medical Provider Amount Bitted ($) Amount Paid ($)
the doctor & Diagnosis (DDi MM/YY)

Dr Alice Khieu Exams & Tooth Extract 29t05t2020 243.00 243.00

Dr Alice Khieu Tooth Extraction 06t06t2020 221.00 221.00

SECTION E: AUTHORIZATION AND CERT!FICATION

information witl be used only for the purpo$s of providing you with the requested insurance serices. Ltoydt and lntrepid's complete priEcy poticies are availabte upon request

oti.r surcc for 166 omd und.r thb potic,y, ud uthorlz. nd dlr.ct ucfi p.y.rr to fomrd prymilt dLtcdy to Lloldl .td hErpld. I confrm brtow by nry 3tlr.tun ttrt t
rm rl.tholtadb rcton brhelf of enyof nyd.p$d.nltftrtlr... pul?omjA phecopy of l,ib afihor&rtim.ftdl b...yrod rl'E orlaflhl.
I canflythdth.lllionnruolr prqrHrd ln onn*donwl0r tlrb clelm lr cmpbo, tnr., ud rBurd..

Name of lnsured (ptease print) Mokhammad NasrulAnas

lf lnsured is under age 16, futt name of parent/tegal guardian (ptease print)

Signature of lnsured (if under age 16, signature of parent or [ega[ guardian) Signature of poticyhotder-omttr6i insurance in Section B, if appticabte

SECTION F: AUTHORIZATION TO PAY

THIS CLAIM lS PAYAALE TO3

E lnsured at t}re addross in Section A above IParent/cuardian nHospitat/Ctinic tr Physician

EI other: lf appticabte, I authorize payment of this ctaim to (ptease print): NasrulAnas
Date signed (DD/MM/YY):

tN THE EVENT OF AN EMERGENCY PLEASE CONTACT INTREPID 2417" IMMEDIATELY AT:

1.866.883.9787 +1 416.640.7865
tott-free from canada and the USA coltect where availabLe
e- mai [: intrepid@intrepid247.com
CLAIMS SUBMISSION:
lntrepid 24/7* 1.866.883.9485 +1 416.640.7862
150 King St West, Suite 602 - PO Box 75, totl-free from Canada and the USA coLlect where avaiLabLe
Toronto ON MsH 1J9
clal ms@intrcpid 247,com
fax: +1 416.730.1878