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 benefit 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-BI / 942-2756-BI)
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-BI-E / 4197-OPT-CI-BI-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]


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