Pacific first claim system

You DO NOT need to login to submit a claim

Welcome to the secure Pacific First claim form. Please fill in all of the mandatory fields. Incomplete or inaccurate applications will delay your claim processing.

Personal profile

Plan Number

Employer Name

Employee's First Name

Employee's Last Name

Employee's Email Address

Employee's Date of Birth

Please note that due to potential Canada Post service disruption we STRONGLY recommend that you use direct deposit to receive any claim remunerations.

Do you want direct deposit? No
Yes [See Void Cheque instructions beside or below]

If you have NOT previously uploaded a void cheque, or if your banking information has changed, please upload a void cheque here.

Claim details

Please ensure that each and every claimed expense is itemized separately otherwise they cannot be processed.

Patient full name

Date of purchase/service

Description

Claim amount

Click to add more patients

Total claim amount: $0

Claim upload [Total of all files should not exceed 60MB]

Upload claim (you can select multiple files at a time)

Click to upload more supporting files

I agree to Terms of Use

Toll-Free: 1-800-345-5515
Phone: (604) 293-1974
Fax:(604) 293-0344

208 - 3970 Hastings Street
Burnaby, BC, V5C 6C1
info@pacific-first.com