Ambassador, CANUS and Welcome Plan Claim Forms

These documents are in PDF format. To view and print them, you need Adobe Acrobat Reader Version 4.0 or higher, which you can download, at no cost, from the Adobe website.

Ambassador claim forms

These forms are for plan members who are covered under the Ambassador plan with Lloyd's of London.

• Ambassador Medical Claim Form M635D(AMB) BIL
• Ambassador Dental Claim Form M445D(AMB) BIL
• Ambassador AD&D Claim Form M5984
• Ambassador Disability Claim Form M5983
• Ambassador Medical Reimbursement Plan Claim Form M6107BIL

CANUS claim forms

These forms are for plan members who are covered under the CANUS plan with UniCare.

• CANUS Dental Claim Form M6216
• CANUS Health and Accident Claim Form M6217
• CANUS Life Claim Form M6593
  (Note: the last page of this form must be completed by the plan administrator.)
• CANUS Prescription Drug Reimbursement Form
• CANUS Vision Care Claim Form
• CANUS Accidental Dismemberment or Loss of Sight Claim Form
• CANUS Short-Term Disability Claim Statement
• CANUS Long-Term Disability Claim - Physician’s Statement M6583
• CANUS Long-Term Disability Claim - Employee’s Statement M6584
• CANUS Long-Term Disability Claim - Employer’s Statement M6585

Welcome Plan claim forms

These forms are for plan members working in Canada, who are not eligible for government healthcare coverage and are covered by Welcome Plan.

• Welcome Plan Claim Form M635D(WP)