Forms

Administration

Individual insurance

PDF_32 Authorization.pdf PDF_32 Additional health declaration due to COVID-19.pdf PDF_32 Beneficiary Designation Form.pdf PDF_32 Cancellation Request Form.pdf PDF_32 Pre-authorized Debit (PAD) Agreement.pdf PDF_32 Short Health Statement – Disability due to accident (Flex Plan) PDF_32 Short Health Statement.pdf PDF_32 Method of payment.pdf

Travel insurance

PDF_32 Early Return - Premium Reimbursement Request.pdf PDF_32 Travel Insurance Modification Request.pdf

Contracting & Commissions

PDF_32 Request for Payment Direct Deposit.doc

Underwriting

PDF_32 List of occupations PDF_32 Overhead Expenses PDF_32 Arthritis questionnaire PDF_32 Truck Driver questionnaire PDF_32 Driving questionnaire PDF_32 Diabetes questionnaire PDF_32 Epilepsy questionnaire PDF_32 Backache and/or Musculoskeletal Problems questionnaire PDF_32 Special questionnaire for migraines (headaches) PDF_32 Occupation questionnaire PDF_32 Nervous Disorder questionnaire PDF_32 Respiratory Problems questionnaire PDF_32 Drug Usage questionnaire PDF_32 Tobacco Usage questionnaire PDF_32 Foreign Travel questionnaire

Claims

Health and dental insurance

This form is used for health care benefits, such as medical or paramedical expenses, drugs and vision care.
Complete this form online, save it, print and sign it, and mail it to us along with your original receipts.
Important: Claims must be submitted no later than 12 months after expenses are incurred.

The Claimant's Statement is provided with the Hospitalization Certificate. Both are required for any claim under one of the following benefits: hospitalization, hospital allowance or daily indemnity. They may also be used to claim ambulance transportation expenses.
Important: The Hospitalization Certificate must be completed by an authorized agent.

This form is used for dental claims. In most cases, your dentist will be able to submit claims automatically through an electronic data interchange (EDI) system.
If your dentist has EDI, you'll just need to provide your policy and ID numbers. Your dentist will electronically submit your claim to us, and we'll mail you or your dentist a reimbursement cheque for any eligible expenses.
If your dentist does not have EDI, please submit the completed and signed dental claim form provided to you by your dentist.

The Claimant's Statement must be provided with the Attending Physician’s Statement. Both are required for any claims related to an accidental fracture.

The Claimant's Statement, Attending Physician’s Statement and Medical Certificate are required for any claims filed for medical care costs related to a critical illness covered by the contract.
Important: The Medical Certificate must be completed by an authorized agent if the insured received out-patient treatments or home health care.

The Claimant's Statement and Attending Physician’s Statement are required for any claims related to accidental loss of use or accidental dismemberment.

Disability insurance – Initial claim

The Claimant's Statement and Attending Physician’s Statement are required for any claims related to accidental loss of use or accidental dismemberment.

This form is required to file a claim for the overhead expenses benefit. You must also provide all supporting documents for each of your expenses.
Because your overhead expenses claim is related to a sick leave, you must complete the claim forms for disability benefits, which are included in the claimant's guide to disability insurance. If your claim is related to the overhead expenses benefit only, you don't need to provide proof of income.
Note that since changes in expenses may occur during a disability period, supporting documents may be requested regularly during your leave.

This form is required if you file a claim for Mortgage Plan; you must also provide proof of the last payments made to the creditor.
Because your Mortgage Plan claim is related to a leave of absence, you must complete the claim forms for disability benefits, which are included in the claimant's guide to disability insurance.
If your claim is related to Mortgage Plan benefit only, you don't need to provide proof of income.
In case of variable interest, some changes may occur in the payments to the creditor. Note that supporting documentation may be requested regularly during your disability period.
Be advised that the direct deposit option is not authorized in the case of claims related to a mortgage loan or any other type of loan.

This form is required for any Long Term Care Insurance coverage.

Disability insurance – Claims during a disability period

This authorization allows the insurer to obtain information that is necessary to assess your claim. Use this form if you are asked for a recently signed, original authorization.

This form is required to confirm your date of return to work and to reinstate the automatic benefit increase option on coverage that would have been suspended during the work stoppage. A Medical Certificate specifying the date of return must be submitted with this form.

This form may be required if the description of the accident given on the Claimant’s Statement and included in the initial claim is considered incomplete.

This report is necessary when a claim is filed under the overhead expenses benefit.
Expense reports and supporting documents are regularly requested during a period of disability. Generally, this information is required every three months as we must ensure that current expenses are equal to the insured amount.

If the insured person has more than one employer, this form may be used to provide a copy to be completed. The form may also be used if the insured person is disabled again after attempting to return to work. In this case, the employer must complete the form again.

If your disability leave has been extended, this form must be completed by your attending physician or specialist. Updated clinical notes and the last medical reports must be attached.

Use this form if you did not choose direct deposit as the method of payment on your initial claim. Simply complete the form and attach a VOID cheque.
Please note that this method of payment is not available if you file a loan or mortgage claim as payments are made directly to your creditor.