BANKING INFORMATION

health insurance
REQUEST FORM
PLEASE USE BLOCK LETTERS, TYPE OR PRINT WHEN COMPLETING THIS FORM

PROVIDER NUMBER

Our preapproval process ensures that you are prepared to begin submitting Canopy claims with no further actions required. However,
for your convenience, we suggest that you complete the information below in order to facilitate electronic reimbursement of claims.*

Legal name of Sole Proprietor/Responsible Person (for non-sole proprietorship)

SURNAME FIRST NAME MI

Business Name Cell Number

Business Address Office Number

Mailing Address (If different from Business Address)

Email Address

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BANKING INFORMATION

BANK NAME BANK BRANCH

ACCOUNT ACCOUNT TYPE SAVINGS CHEQUING

NAME

ACCOUNT NUMBER

I confirm that the information provided is true and correct and can be relied upon by Canopy Insurance Limited and hereby grant permission for the
usage of the information for the purposes herein stated or as may be required from an operational standpoint.

Name Signature Date

*The processing of your first Canopy claim, whether through swipe or paper claim, represents the activation of your provider number and your acceptance of the Canopy Terms and Conditions enclosed
in your pre-approval package. Payments will be made via cheque to providers who have not submitted their banking information to Canopy.

www.canopy-insurance.com 888-4-CANOPY p owe re d by