Penfield - New Claim

Submit Travel Medical Claim

Initiate your claim by completing each step.

Patient

Emergency

Expenses

Insurance

Uploads

Patient Profile

First Name *

Last Name *

Date of Birth *

Telephone Number *

Email Address *

Confirm Email Address *

Street Address Line 1 *

Suite / Apt (Opt)

City *

Province/State *

Postal / Zip Code *

Country *

Emergency Details

Date of Emergency *

Policy / Contract Number *

Nature of Medical Emergency *

Type of Services Provided (Select all that apply)

Walk-in / Urgent Care Clinic Emergency Hospital Visit Family Physician X-Rays / Ultrasound Physiotherapy / Chiropractor Other Specialist Services

Family Doctor in Home Country (Name, Phone, Location) *

Expenses & Reimbursement

Did you incur out-of-pocket medical expenses? *

YES, I incurred out-of-pocket expenses NO, I did not incur expenses

Medical Expense List (Detail your out-of-pocket bills, dates, and amounts)

Who is receiving the reimbursed funds? *

Policy Holder Other Authorized Recipient

How would you like eligible funds to be sent? *

Cheque E-transfer Wire Transfer

Mailing Address for Cheque *

E-transfer Email or Wire Details (Bank Name, Transit #, Account #, SWIFT/IBAN) *

Coordination of Benefits

Are you entitled to benefits under any other insurance plan? *

Yes, I have other coverage No other coverage

Do you have a credit card with travel insurance? *

Yes No

Trip Timeline

Arrival at Destination *

Departure to Home Country *

Document Attachments

Proof of Travel * (Itinerary, boarding pass, or passport stamp)

Attach Medical Documents (Doctor's notes, diagnostics, logs)

Invoices, Receipts, or Credit Card Statements

Authorization & Consent

I authorize Penfield Medical Cost Containment, healthcare providers, and partners to exchange personal information necessary to investigate and process my medical claim. * I declare that all details in this claim form are true, correct, and complete to the best of my knowledge. *

E-Signature Name (Type Full Legal Name) *

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