Select forms

Instructions

Step 1 : Fill out and sign the form. Step 2 : Gather original supporting documents. Step 3 : Send everything to the address indicated on the form.

Prior to sending one of the following forms, please contact our Customer Contact Centre since other documents may be required. Scanned documents are not accepted.

Telephone: 1-888-558-5525 or 514-285-3000, 1-800-361-7285 (U.S.)
Fax: 1-855-557-7374 or 514-285-3290 (outside Canada)

Forms


Declaration of Attending Physician - Original Request – 02025A (PDF, 607 KB)

This form is filled out by the attending physician at the first appointment regarding a short- or long-term disability benefit claim.

Important:

This form has 2 sections. Make sure your physician only fills out the section that applies to your situation. For any follow-up assessments, the attending physician must fill out form 02026A. The insured is responsible for any fees related to this form. To be completed by the insured and the attending physician


Declaration of Attending Physician - Additional Report – 02026A (PDF, 874 KB)

This form is filled out by the attending physician at subsequent medical appointments to monitor a short- or long-term disability.

Important:

The insured is responsible for any fees related to this form.


Disability claim Select – 12054E (PDF, 893 KB)

Form to fill out and sign when submitting a disability claim according to the warranty chosen by the insured.

Important:

Certain documents are required in order to process your claim. Incomplete or missing documents may delay this process.


Additional statement Select – 12109E (PDF, 567 KB)

Form to fill out if you have the Residual or Partial Disability option and you have to provide details about a return to work.


Disability income business expense Select – 12110E (PDF, 580 KB)

Form to fill out if you have the Business Expense coverage and you have to detail the costs incurred by your company for a total disability period.


Detailed statement of overhead expenses and income earned in the case of residual disability Select – 12111E (PDF, 572 KB)

Form to fill out if you have the Residual Disability option and the Business Expense coverage and you have to detail the costs incurred by your company and your income earned during this period.


Business expense statement SOLO – 09110E (PDF, 329 KB)

To fill out when you have the business expenses coverage and you have to detail the costs incurred by your company for a total disability period.

Important:

Valid for the SOLO NEXUS, SOLO NEXUS V2 and Select products.


Detailed statement of overhead expenses and income earned in the case of residual disability SOLO – 09111E (PDF, 513 KB)

To fill out when you have the residual disability option and you have to detail the costs incurred by your company and your income earned during this period.

Important:

Valid for the SOLO NEXUS, SOLO NEXUS V2 and Select products.