Out-of-Country Claim Forms
Policy Range 1
This form is for group plan members with out-of-country healthcare coverage, with a group plan number that falls between one of these number ranges:
- 56000 to 56300
- 56461 to 56599
- 250000 to 256499
- 330000 to 339999
- 340000 to 344999
If your group plan number falls between one of these number ranges, please complete the Out-of-Country / Province & Authorization Form.
If you live in Quebec, please also complete the Power of Attorney form in addition to the Out-of-Country / Province & Authorization Form.
If your group plan number does not fall within the above numbers, use the out-of-country claim forms in the Policy Range 2 section instead.
If you are unsure of which forms you should use, call our Out-of-Country Claims department at 1-800-957-9777.
| 
