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Critical Illness – Bacterial Meningitis, Benign Brain Tumor, Coma, Stroke

Choose how to get the form and submit

1

Step 1

step

Print the form once downloaded

Download the Form Here
2

Step 2

step

Fill in the form using blue ink pen

3

Step 3

step

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

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