Critical Illness – Kidney Failure Major Organ Transplant or Failure on Waiting List Aplastic Anemia

Print the form once downloaded

Fill in the form using blue ink pen

Once the form is completely filled out this needs to be submitted with an accompanying

1. Cover Page & Instruction Sheet (download here)

2. Claimant Statement (download here)

3. Physician Statement (this form)

Please scan / take high resolution photos of all documents and Upload Here

These forms can also be submitted in person or mailed at:
LiUNAcare Local 506
3750 Chesswood Drive, Suite 1
Toronto, ON M3J 2W6