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:

  • 55275
  • 55440
  • 56000 to 56300 (exception policy 56048)
  • 56461 to 56599
  • 56891
  • 57134
  • 157966
  • 250000 to 256499
  • 330000 to 339999 (exceptions: policy 330864 and policy 335206)
  • 340000 to 344999

If your group plan number falls between one of these number ranges, please complete the out-of-country / province & authorization form {M6639}.

NOTE: For services incurred outside Canada that were not for emergencies (for example, massage therapy), please remit these completed forms to: PO Box 6000, Winnipeg, MB  R3C 0A5.

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.