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To order more forms and supplies, please complete this form then click on the Submit button at the end.
Shipping Address * :
(supplies cannot be shipped to P.O. Boxes)
Quantity Needed
Enrolling and Terminating Employees or Updating Information
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
Making Claims
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)
*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.