Canopy

BANKING INFORMATION REQUEST FORM

Our preapproval 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 reimbursment of claims.*

Provider Number

*Find this number in your pre-approved package

BUSINESS CONTACT INFORMATION

Surname

First Name

Business Name

Cell Number

Business Address

Parish

Office Number

Mailing Address

Parish

Email Address

BANKING INFORMATION

Bank Name

Bank Branch

Account Name

Account Type

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.

*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.