Request for Supplies

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

Company Information

Shipping Address*

(supplies cannot be shipped to P.O. Boxes)

0/500

Administration Supplies

Enrolling and Terminating Employees or Updating Information. Please enter the quantity needed.

Authorization Card

(Bilingual) (940-3940)
(Bilingual) (940-3940)

Enrollment/Change Form

(PA only) (945-0735/6)
(PA only) (945-0735/6)

Health Statement

(3484-BASIC-OPT-CI-MSD-E/F)
(3484-BASIC-OPT-CI-MSD-E/F)

Travel Benefit with Med-Passport

(GB00200-E/F)
(GB00200-E/F)

Travel Benefit

(GB00201-E/F)
(GB00201-E/F)

Insurance options for Plan Members on Termination of Group Benefits

(4262-E/F)
(4262-E/F)

Refusal of Group Insurance Card

(940-0280/1)
(940-0280/1)

Smoker/Non-Smoker Declaration

(940-3300/1)
(940-3300/1)

Enrolment Form

(with member address) (942-2755/6)
(with member address) (942-2755/6)

Group benefits enrolment form for plans with optional Life and/or Critical Illness

(4197-CI-E/F)
(4197-CI-E/F)

Beneficiary Nomination

(102G-E/F)
(102G-E/F)

Beneficiary Nomination with Optional Benefits

(102G-OPT-E/F)
(102G-OPT-E/F)

Employee Benefits Booklets

Please enter the quantity needed.

Employee Benefits Booklets

Employee Benefits Booklets

Claims Supplies

Making claims. Please enter the quantity needed.

Election of Method of Settlement and Statement of Claim

(490-CS-E/F)
(490-CS-E/F)

Election of Method of Settlement and Statement of Claim:

Physician Statement (490-PS-E/F)
Physician Statement (490-PS-E/F)

Waiver of Premium Claimant Statement

(4203-E/F)
(4203-E/F)

Employer's statement

(4205-E/F)
(4205-E/F)

Notification of Death

(Bilingual) (020-3252)
(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.

Other Supplies

Please enter the quantity needed.