Request for Supplies

To order more forms and supplies, please complete this form then click on the Submit button at the end.

Company Information

Company Name :
Contract Number :
Billing Group :
Shipping Address :
(supplies cannot be shipped to P.O. Boxes)
Postal Code :
Contact Person :
Telephone Number :
E-mail :
Administration Supplies Quantity Needed
Enrolling and Terminating Employees or Updating Information English French
Authorization Card (Bilingual) (940-3940)
Enrollment/Change Form (PA only)
(945-0735/6)
Health Statement (3484-BASIC-OPT-CI-MSD-E/F)
Travel Benefit with Med-Passport (GB00200-E/F)
Travel Benefit (GB00201-E/F)
Insurance options for Plan Members on Termination of
Group Benefits (4262-E/F)
Refusal of Group Insurance Card
(940-0280/1)
Smoker/Non-Smoker Declaration
(940-3300/1)
Enrolment Form (with member address) (942-2755/6)

Group benefits enrolment form for plans with optional Life and/or Critical Illness (4197-CI-E/F)
Beneficiary Nomination (102G-E/F)
Beneficiary Nomination with Optional Benefits (102G-OPT-E/F)

Employee Benefits Booklets Quantity Needed
  Class English French
Employee Benefits Booklets
Employee Benefits Booklets
Claims Supplies Quantity Needed
Making Claims English French
Election of Method of Settlement and Statement of
Claim (490-CS-E/F)
Election of Method of Settlement and Statement of Claim:
Physician Statement (490-PS-E/F)
Waiver of Premium Claimant Statement
(4203-E/F)
Employer's statement (4205-E/F)
Notification of Death (Bilingual) (020-3252)
Dental Claim Form/ with Health Spending Account?* Yes No

Medical Claim Form/ with Health Spending Account?* Yes No

*Note: If ordering medical or dental claim form, please specify if you require Health Spending Account by answering the question. If left blank, we will provide claim form without Health Spending Account.

Other Supplies Quantity Needed
Please Specify         English French