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Request for Supplies

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)

Administration Supplies

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

Quantity Needed

Employee Benefits Booklets

Employee Benefits Booklets

Claims Supplies

Quantity Needed

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) 

Dental Claim Form/ with Health Spending Account?*
Medical Claim Form/ with Health Spending Account?*

*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