Forms
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Administrative Forms
| Form name | Purpose | Audience | File details |
| Administration Guide (GB10052-E / GB10052-F) |
Insurer Administered Plan administrator guide | Plan sponsor | [PDF, 33 pages, 551 KB] |
| Administration Guide – Health Spending Account | Plan administrator guide – Health Spending Account | Plan sponsor | [PDF, 8 pages, 88 KB] |
| Application - SunAdvantage (047-0430 / 047-0431) |
Use this form to submit your request for SunAdvantage group benefit contract set up. | Plan Advisor | [PDF, 5 pages, 443KB] |
| Beneficiary nomination (102G-E / 102G-F) |
Use this form to nominate or change a beneficiary for your Life and AD&D benefits | Plan member Plan sponsor |
[PDF 2 pages, 72 KB] |
| Beneficiary nomination with Optional benefits (102G-OPT-E / 102G-OPT-F) |
Use this form to nominate or change a beneficiary for your optional benefits | Plan member Plan sponsor |
[PDF, 2 pages, 76 KB] |
| Consent by beneficiary (102C-E / 102C-F) |
Use this form if you need to add, change, or update your irrevocable beneficiary | Plan member Plan sponsor |
[PDF, 1 page, 125 KB] |
| Cost plus coverage (042-0830 / 042-0831) |
Use this form when submitting a request for SunAdvantage cost plus claims payment | Plan sponsor | [PDF, 3 pages, 210 KB] |
| Employee Data Sheet | Use this form along with the request for quotation form | Plan advisor | [PDF 2 pages, 46 KB] |
| Enrolment form (942-2755 / 942-2756) |
Use this form when enrolling for group benefits | Plan member Plan sponsor |
[PDF, 3 pages, 137 KB] |
| Enrolment form for plans with optional life (4197-OPT-CI-E / 4197-OPT-CI-F) |
Use this form when enrolling for group benefits if your plan offers optional benefits Plan member | Plan sponsor |
[PDF, 3 pages, 156 KB] |
| Health Statement (3484-SLS-E / 3484-SLS-F) |
If excess / increased coverage is required or the plan member is a late applicant or the information is being re-submitted | Plan member Plan sponsor |
[PDF, 4 pages, 172 KB] |
| Insurance options for plan members on termination of group benefits (4262-E / 4262-F) |
Use this form if you are losing coverage under the group plan and want information about continuing your benefits. | Plan sponsor |
[PDF, 1 page, 85KB] |
| Insurance Tax Forms (4297-E / 4297-F |
Ontario Retail Sales Tax remittance election form | Plan sponsor |
[PDF, 2 pages, 17 KB] |
| Pre-Authorized Debit Agreement (300B-E/F) |
Use this form to pay premiums automatically | Plan sponsor |
[PDF, 1 page, 128 KB] |
| Refusal of Insurance (947-0320 / 947-0321) |
Use this form when an employee declines to participate in the group insurance plan | Plan member Plan sponsor |
[PDF, 1 page, 93 KB] |
| Request for Quotation (4134-E / 4134-F) |
Use this form when requesting a quote for SunAdvantage group benefits business | Plan advisor | [PDF, 3 pages, 262KB] |
| Travel Benefit and Medi-Passport Brochure and Card (GB00200-E / GB00200-F) |
Provide your plan member with this brochure if your group benefits plan offers Travel Assistance | Plan member Plan sponsor |
[PDF, 2 pages, 133 KB] |
Approval Forms
| Form name | Purpose | Audience | File details |
| Prior Authorization Forms | Includes forms required for the approval of prior authorization drugs. | Plan member Plan sponsor |
Claim Forms
Dental
| Form name | Purpose | Audience | File details |
| Dental claim – standard (DENT- E / DENT - F) |
Use this form when you want to make a standard dental claim | Plan member Plan sponsor |
[PDF, 2 pages, 608KB] |
| Dental with health spending account claim form (DENT-HSA-E / DENT HSA-F) |
Use this form when you want to submit a dental claim under your health spending account | Plan member Plan sponsor |
[PDF, 2 pages, 348 KB] |
Disability
| Form name | Purpose | Audience | File details |
| Disability – Long Term – Plan Member package | Includes forms required for the submission of a LTD claim | Plan member | [PDF, 20 pages, 1023 KB} |
| Disability - Long Term - Plan Sponsor package | Includes forms required for the submission of a LTD claim | Plan sponsor | [PDF, 8 pages, 894 KB] |
| Disability - Short Term - Plan Member package | Includes forms required for the submission of a STD claim | Plan member | [PDF, 15 pages, 917 KB] |
| Disability - Short Term - Plan Sponsor package | Includes forms required for the submission of a STD claim | Plan sponsor | [PDF, 7 pages, 710 KB] |
Extended Health Care
| Form name | Purpose | Audience | File details |
| Extended health care - Standard claim form (EHC-E / EHC-F) |
Use this form for all medical expenses and services claims | Plan member Plan sponsor |
[PDF, 2 pages, 341 KB] |
| Extended health care - Health spending account claim form (EHC-HSA-E / EHC-HSA-F) |
Use this form for all medical expenses and services to be claimed under your health spending account | Plan member Plan sponsor |
[PDF, 2 pages, 342 KB] |
Life
| Form name | Purpose | Audience | File details |
| Notification of death (020-3252) |
Use this form when submitting a death notification. | Plan sponsor | [PDF, 2 pages, 257 KB] |
| Election of method of settlement & statement of claim (490-CS-E / 490-CS-F) |
Use this form when submitting a life claim as a designated beneficiary. | Plan member | [PDF, 2 pages, 77 KB] |
| Election of method of settlement and statement of claim: Physician statement (490-PS-E / 490-PS-F) |
A completed Physician Statement is acceptable in lieu of an original or certified copy of a provincial death certificate. A completed Physician Statement is required if death occurs within two years of coverage being approved or, if the benefit is more than $250,000 and coverage has been in effect for less than five years. This is in addition to an official death certificate. |
Plan member | [PDF, 1 page, 148 KB] |
| Waiver of Premium Claim – Employers statement (4205-E / 4205-F) |
Use this form when submitting a waiver of premium claim notification. | Plan sponsor | [PDF, 1 page, 293 KB] |
| Waiver of Premium Claim – Claimant’s statement (4203-E / 4203-F) |
Use this form when submitting a waiver of premium claim by the plan member. | Plan member | [PDF, 6 pages, 212 KB] |
| Waiver of Premium Claim – Physician (4202-E/4202-F) |
Use this form to support a claim for waiver of premium. | Plan member | [PDF, 5 pages, 237 KB] |
The above files are in Adobe Acrobat format. If you don't already have Adobe Acrobat Reader, you can download it here:
