Follow the steps to successfully complete your online claim form.

1. Press the ‘Get Form’ button to access the claim form and open it in your preferred editing tool.
2. Complete Part 1 – Employee Information. This section requires the employer's name, your full name, and address details, including box number or apartment number, street, city, province, and postal code. Do not forget to include your Employee I.D. number from your ASSURE card.
3. Indicate if this claim is an adjustment to a previously paid claim by selecting 'Yes' or 'No'.
4. Move to Part 2 – Claimant Information. Provide the details for each claimant, including their name, patient code (refer to the provided codes), date of birth, the number of receipts, and the total amount charged. Ensure you have original pharmacy receipts attached for the drugs being claimed.
5. If applicable, complete Part 3 – Overage Student Information by entering the name and address of the school for covered overage students.
6. In Part 4 – Co-ordination of Benefits, indicate whether the claimant's spouse is covered by any other health plan or insurance. If 'Yes', provide the name of the other plan, group policy number, certificate or ID number, and the spouse’s date of birth.
7. If the claim involves out-of-country expenses, fill out Part 5 – Out of Country Claim. Include the country of purchase, currency used, nature of illness, purpose of travel, departure date, and actual return date.
8. Read and acknowledge the privacy statement regarding personal information. Provide your signature and the date at the end of the form to certify that the information is true and complete. It is important to keep a copy of the completed form for your records.
9. Once all sections are completed, save your changes, and download or print the form for your submission.

Complete your Great West Life Claim Form online today for a seamless claims experience.