Forms

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Form Name
File Details
Purpose
Administration Guide [PDF,33 pages,551kb] Plan administrator guide
Administration Guide - Health Spending Account [PDF,8 pages,88kb]

Administration Guide - Health Spending Account
Application [PDF,5 pages,154kb]

Plan sponsor makes application for insurance and Advisor submits plan details

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Form Name
File Details
Purpose
Beneficiary Nomination [PDF,2 pages,113kb]

Nominate beneficiaries for Employee Life and Accidental Death benefits
Beneficiary Nomination with optional benefits [PDF,2 pages,159kb]

Nominate beneficiaries for Employee Optional Life and Accidental Death benefits

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Form Name
File Details
Purpose
Claims - Dental & Health Spending Account Claim Form [PDF,2 pages,348 KB] Make a standard dental claim as well as a Health Spending Account claim
Claims - Dental claim - standard [PDF,2 pages,608kb]

Make a standard dental claim
Claims - Extended Health Care Claim - standard [PDF,2 pages,341kb]

Claim all medical expenses and services
Claims - Extended Health Claim & Health Spending Account Claim Form [PDF,2 pages,342 KB] Claim all medical expenses and services as well as a Health Spending Account claim
Cost Plus Benefit Coverage [PDF,3 pages,210kb]

Submit a Cost Plus claim

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Form Name
File Details
Purpose
Disability - Long Term - Notice of Claim - LTD [PDF,1 pages,52kb]

Make an LTD claim
Disability - Questionnaire - Job Demands [PDF,3 pages,286kb]

Support for an STD claim
Disability - Short Term - Attending Physician's statement - general - STD [PDF,4 pages,90kb]

Support for an STD claim - physican
Disability - Short Term - Claim Guide [PDF,8 pages,362kb]
Disability - Short Term - Claim form - Plan Sponsor's statement - STD [PDF,3 pages,137kb]

STD claim statement - employer statement
Disability - Short Term - Claim form - Plan member's statement - STD [PDF,4 pages,193kb]

STD claim statement - employee

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Form Name
File Details
Purpose
Election of method of settlement & statement of claim [PDF,2 pages,163 KB]

submit a claim for settlement of death
Election of method of settlement and statement of claim: Physician statement [PDF,1 pages,135 KB]
Employee Data sheet (Use with RTQ) [PDF,1 pages,26kb]

List of employee information when requesting a quotation
Enrolment form [PDF,3 pages,184kb]

Employee, spouse and dependent information for plan enrolment
Enrolment form with Optional Life [PDF,3 pages,210kb]

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Form Name
File Details
Purpose
Insurance options for plan members on termination of group benefits [PDF,1 pages,150 kb]

Employee can convert life coverage when leaving the group plan
Insured Tax Forms [PDF,2 pages,17kb]

Ontario Retail Sales Tax remittance election form

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Form Name
File Details
Purpose
Notification of Death [PDF,2 pages,162 KB]

submit a notification of death

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Form Name
File Details
Purpose
Pre-authorized chequing [PDF,1 pages,128kb]

Plan sponsor - Pay premiums automatically

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Form Name
File Details
Purpose
Refusal of Insurance [PDF,1 pages,93kb]

Employee Refusal of  group insurance
Request for Quotation (RTQ) [PDF,3 pages,173kb]

Advisor use - identify plan details to receive a quotation
Request for supplies [PDF,1 pages,315kb] Order booklets and from supplies

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Form Name
File Details
Purpose
Statement of health [PDF,4 pages,172kb]

If excess / increased coverage is required or the plan member is a late applicant or the information is being re-submitted

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Form Name
File Details
Purpose
Travel benefit Medi-Passport [PDF,2 pages,133kb]

Employee Health benefits when out-of-country

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