All forms

Group Insurance - Claims
Medical Expenses
Quebec	Rest of Canada
Claim for Health Care Benefits - 19132A Used to submit claims for prescription drugs, services provided by a healthcare professional, or paramedical or vision care. Insureds have a maximum of 1 year from the date on which the expenses are incurred to submit a claim. Health Care Claim Quick Reference - 10075E Document with important information on health claims processing.	Claim for Health Care Benefits - 19132A Used to submit claims for prescription drugs, services provided by a healthcare professional, or paramedical or vision care. Insureds have a maximum of 1 year from the date on which the expenses are incurred to submit a claim. Health Care Claim Quick Reference - 10075E Document with important information on health claims processing.
Dental Expenses
Quebec	Rest of Canada
Claim Form for Dental Care Expenses - 19110A Used to submit dental claims. Complete this form electronically, print and sign it, and then mail it to us with your original receipts.	Claim Form for Dental Care Expenses - 1911001A Used to submit dental claims. Complete this form electronically, print and sign it, and then mail it to us with your original receipts.
Travel Insurance
Quebec	Rest of Canada
Hospital and Medical Expenses Claim Form - Quebec Residents Only - 15638A Completed by Quebec residents so that insureds or service and care providers are reimbursed promptly for expenses incurred outside Quebec. Also authorizes us to submit claims to the RAMQ on behalf of the insured. Supporting documents must be included with the claim. Claim - Attending physician's statement (Travel Insurance) - 15541A Please do not have this form completed, unless instructed otherwise by the insurer.	Claim Form (Travel Insurance) - 08022E Form that must be submitted with any claim for healthcare expenses incurred outside your province of residence and sent with the assignment of your province of residence. Claim - Attending physician's statement (Travel Insurance) - 15541A Please do not have this form completed, unless instructed otherwise by the insurer. Refunding for health care - 02027E Alberta - Agreement Refunding for health care - 02025E British Columbia – Assignment of payment Refunding for health care - 02028E Prince Edward Island - Agreement Refunding for health care - 01228E New Brunswick - Agreement Refunding for health care - 02029E Nova Scotia - Agreement Refunding for health care - 15902A Authorization and release - Ontario Ministry of Health and Long-Term Care Refunding for health care - 02026E Saskatchewan - Assignment of payment Refunding for health care - Newfoundland and Labrador Newfoundland and Labrador Mandate
Disability
Quebec	Rest of Canada
Disability Claim - 98124E Used to submit short- or long-term disability claims. The employer completes and signs the Employer's Statement to confirm that the plan member is eligible, and the plan member then completes and signs the Employee's Statement. Notice of Return to Work - 00159E This form should be completed by the employer and sent to us the same day the employee returns to work after receiving disability benefits. Declaration of Attending Physician - Original Request - 02025A Completed by the attending physician when a short- or long-term disability claim is first submitted. Form no. 02026A is used for subsequent medical assessments. The insured is responsible for any fees related to this form. Declaration of Attending Physician - Additional Report - 02026A Must be completed by the attending physician for assessing how the disability is progressing. The insured is responsible for any fees related to this form. Claim - Convalescent Care - 98130E Used to submit claims for home care services, provided these expenses are covered under the policy. The physician who recommended the convalescent care must complete the form, and supporting documents must be included with the claim.	Disability Claim - 98124E01 Used to submit short- or long-term disability claims. The employer completes and signs the Employer's Statement to confirm that the plan member is eligible, and the plan member then completes and signs the Employee's Statement. Declaration of Attending Physician - Original Request - 0202501A Completed by the attending physician when a short- or long-term disability claim is first submitted. Form no. 0202601A is used for subsequent medical assessments. The insured is responsible for any fees related to this form. Declaration of Attending Physician - Additional Report - 0202601A Must be completed by the attending physician for assessing how the disability is progressing. The insured is responsible for any fees related to this form. Claim - Convalescent Care - 98130E Used to submit claims for home care services, provided these expenses are covered under the policy. The physician who recommended the convalescent care must complete the form, and supporting documents must be included with the claim. Notice of Return to Work - 00159E01 This form should be completed by the employer and sent to us the same day the employee returns to work after receiving disability benefits.
Prior Authorization Drugs
Quebec	Rest of Canada
Prior Authorization Drugs	Prior Authorization Drugs
Accidental Loss
Quebec	Rest of Canada
Claim - Accidental Dismemberment or Loss of Sight / Fractures - 02809A Used in the event of accidental loss of a limb or sight, a fracture or loss of use, if covered under the plan. Supporting documents must be included with the claim.	Claim - Accidental Dismemberment or Loss of Sight / Fractures - 0280901A Used in the event of accidental loss of a limb or sight, a fracture or loss of use, if covered under the plan. Supporting documents must be included with the claim.
Death of Member or Dependent
Quebec	Rest of Canada
Death - Claim - 02227A Used if a plan member or a dependent dies. Supporting documents must be included with the claim. Declaration of Status for Deceased Common-Law Spouse - 01311E Submitted along with the Death Claim form when a common-law spouse dies.	Death - Claim - 0222701A Used if a plan member or a dependent dies. Supporting documents must be included with the claim. Declaration of Status for Deceased Common-Law Spouse - 01311E01 Submitted along with the Death Claim form when a common-law spouse dies.
Others
Quebec	Rest of Canada
Our Online Services - For Plan Members - 03239E04 Pamphlet describing how to register for the secure site for plan members so you can access your claims history. Direct Deposit and Electronic Notice Enrollment - 07019E Completed by plan members who want their health and dental claim payments to be deposited directly into their bank account. An email is sent to the plan member to notify them when their claims have been processed. Confirmation of a dependent child's functional impairment - 09296E Form that must be filled out by the insured and the attending physician if a child has functional impairment. Declaration of Dependent Children Aged 18 to 25 or 21 to 25 Inclusive (According to Contract Provisions) - 19131A This form should be used when an insured wishes to obtain a drug payment card coverage for his dependent child aged 18, or aged 21 to 25 inclusively as stipulated in your contract if he is a full-time student. The form confirming the full-time status must be filled out for each school term.	Our Online Services - For Plan Members - 03239E04 Pamphlet describing how to register for the secure site for plan members so you can access your claims history. Direct Deposit and Electronic Notice Enrollment - 07019E Completed by plan members who want their health and dental claim payments to be deposited directly into their bank account. An email is sent to the plan member to notify them when their claims have been processed. Confirmation of a dependent child's functional impairment - 09296E Form that must be filled out by the insured and the attending physician if a child has functional impairment. Declaration of Dependent Children Aged 18 to 25 or 21 to 25 Inclusive (According to Contract Provisions) - 19131A This form should be used when an insured wishes to obtain a drug payment card coverage for his dependent child aged 18, or aged 21 to 25 inclusively as stipulated in your contract if he is a full-time student. The form confirming the full-time status must be filled out for each school term.

Group Insurance - Admin.
Quebec	Rest of Canada
Evidence of Insurability - 20009A This form is required as per your policy provisions and must be completed and printed (both sides), except in the case of dental care insurance. The insured returns the original to us and keeps a copy for their records. Request for Designation or Change of Beneficiary(ies) or Trustee - 20007A Completed when an insured wants to change an irrevocable beneficiary, or designate or add a new beneficiary or trustee. The insured returns the original to us and keeps a copy for their records. Application for enrolment business pre-authorized debits- 09240E To fill out when you wish to authorize us to withdraw the payment required for your group insurance plan premiums from your bank account. A voided specimen cheque must be attached. Application for Enrolment - 9147A For all new plan members or if group insurance coverage is being reinstated. Must be printed both sides on legal size paper 8½" x 14 Policyholder's Request for Change - 9097A Used for changes to employees' salaries, addresses for billing, claim cheques and mailings; when employees return to work, leave the company or go on disability, etc.; or if there's a change in the policyholder representative. Evidence of Insurability - Critical Illness - 98140E This form is required as per your policy provisions and must be completed if you're applying for critical illness coverage. The insured returns the original to us and keeps a copy for their records. Evidence of Insurability - Dental Care - 20021A This form is required as per your policy provisions and must be completed and printed (both sides) on legal size paper (8½" x 14"). The insured returns the original to us and keeps a copy for their records. Member's Change Request - 04035E Used by plan members to make changes to or cancel their coverages, add optional benefits, request or terminate an exemption, or add or remove eligible dependents. Must be printed both sides on legal size paper 8½" x 14 Notice of Modification - 20017A Used for changes in salary or employment status, or if a plan member becomes disabled. Preparing for a Nurse's Visit - 07072E Pamphlet designed to help plan members prepare for a nurse's visit if we need additional information to assess the insurance application. Questionnaire on Smoking Habits - 02754A Completed by plan members or their spouses who want to take advantage of non-smoker rates. Dependent's Statement - 00291E Used by groups with positive enrolment to add a dependent or update information about a dependent who's already enrolled in the plan. Request for Exemption or Application for Enrolment (Following the Termination of Exemption) - 02757A Used when an insured already has similar coverage under another plan or is applying for previously waived coverage. Request for Forms - 9155A Used to request additional forms. The Designation of Beneficiaries - 08137E Leaflet that provides plan members with general information about choosing a beneficiary and making changes to beneficiary designations.	Evidence of Insurability - 20009A This form is required as per your policy provisions and must be completed and printed (both sides), except in the case of dental care insurance. The insured returns the original to us and keeps a copy for their records. Request for Designation or Change of Beneficiary(ies) or Trustee - 20007A Completed when an insured wants to change an irrevocable beneficiary, or designate or add a new beneficiary or trustee. The insured returns the original to us and keeps a copy for their records. Application for enrolment business pre-authorized debits- 09240E To fill out when you wish to authorize us to withdraw the payment required for your group insurance plan premiums from your bank account. A voided specimen cheque must be attached. Application for Enrolment - 9147A For all new plan members or if group insurance coverage is being reinstated. Must be printed both sides on legal size paper 8½" x 14 Policyholder's Request for Change - 9097A Used for changes to employees' salaries, addresses for billing, claim cheques and mailings; when employees return to work, leave the company or go on disability, etc.; or if there's a change in the policyholder representative. Evidence of Insurability - Critical Illness - 98140E This form is required as per your policy provisions and must be completed if you're applying for critical illness coverage. The insured returns the original to us and keeps a copy for their records. Evidence of Insurability - Dental Care - 20021A This form is required as per your policy provisions and must be completed and printed (both sides) on legal size paper (8½" x 14"). The insured returns the original to us and keeps a copy for their records. Member's Change Request - 04035E Used by plan members to make changes to or cancel their coverages, add optional benefits, request or terminate an exemption, or add or remove eligible dependents. Must be printed both sides on legal size paper 8½" x 14 Preparing for a Nurse's Visit - 07072E Pamphlet designed to help plan members prepare for a nurse's visit if we need additional information to assess the insurance application. Questionnaire on Smoking Habits - 02754A Completed by plan members or their spouses who want to take advantage of non-smoker rates. Dependent's Statement - 00291E Used by groups with positive enrolment to add a dependent or update information about a dependent who's already enrolled in the plan. The Designation of Beneficiaries - 08137E Leaflet that provides plan members with general information about choosing a beneficiary and making changes to beneficiary designations. Request for Forms - 9155A Used to request additional forms.

Accident insurance
Quebec	Rest of Canada
Accirance Accident Insurance	Accirance Accident Insurance

Travel Insurance
Quebec	Rest of Canada
Trip cancellation - 15640A Cancellation Insurance Claim Hospital and Medical Expenses Claim Form - Quebec Residents Only - 15638A Completed by Quebec residents so that insureds or service and care providers are reimbursed promptly for expenses incurred outside Quebec. Also authorizes us to submit claims to the RAMQ on behalf of the insured. Supporting documents must be included with the claim Baggage claim - 15689A Baggage claim form Claim - Attending physician's statement (Travel Insurance) - 15541A Please do not have this form completed, unless instructed otherwise by the insurer.	Trip cancellation - 15640A Cancellation Insurance Claim Baggage claim - 15689A Baggage claim form Claim Form (Travel Insurance) - 08022E Form that must be submitted with any claim for healthcare expenses incurred outside your province of residence and sent with the assignment of your province of residence. Refunding for health care - 02026E Saskatchewan - Assignment of payment Refunding for health care - 02027E Alberta - Agreement Refunding for health care - 02025E British Columbia – Assignment of payment Refunding for health care - Newfoundland and Labrador Newfoundland and Labrador Mandate Refunding for health care - 02028E Prince Edward Island - Agreement Refunding for health care - 02029E Nova Scotia - Agreement Refunding for health care - 01228E New Brunswick - Agreement Refunding for health care - 15902A Authorization and release - Ontario Ministry of Health and Long-Term Care Claim - Attending physician's statement (Travel Insurance) - 15541A Please do not have this form completed, unless instructed otherwise by the insurer.

Change of address
Quebec	Rest of Canada
Change of address	Change of address

Life, health and disability insurance
Quebec	Rest of Canada
Authorization for release of information (CPP) Authorization for release of information (RRQ) Authorization for the collection and communication of personal information (Death) - 98185E01 Authorization for the collection and communication of personal information (Disability) - 98185E Authorization for the release of information (personal information file) Authorization for the release of information - CSST - 05172E Claim - Individual Insurance - accidental dismemberment or loss of sight, fractures - 03031A Claim - Total Long-terme Care - Independent Living - Loss-of-independence Coverage - 06223E Occupational status statement Disability - 10255E Claim for benefits following an accident Occupational status statement Loss of employment benefits - 10256E Claim for loss of employment benefits Claimant's statement - Death claim - 98069E Form to be completed to notice us of death. Death certificate must be attached to the completed form. Critical Illness claim form - Cancer, heart attack, stroke or other illness - Attending physician's statement Critical Illness claim form - Insured's statement Disability claim - Employer of self-employed individual's Statement Disability claim - individual Disabled person's Supplementary Statement Disability Physical Illnesses - RACQ - Additional report Physical Illnesses - RACQ - Original request Pre-Authorized debit agreement (PAD) Payor's authorization Form to be completed to authorize us to withdraw premiums related to your contract from your bank account. Request for cancellation, policy loan, partial surrender or withdrawal of dividens Request for title changes Form to be completed to change the designation of policyowner or beneficiary. Reimbursement agreement for disability benefits overpaid by the insurer - 07147E Payor's authorization for pre-authorized debit (PAD) or credit card payment - 09311E Request for cancellation or partial withdrawal - 00101E13 Statement of good health - 00105E02 Insurability question number 2 on pre-existing conditions - 07043E Application for minor change - 09614A Changes to the savings fund of a Vision contract - 06252E Authorization to disclose medical information to the attending physician – 00103E06	Authorization for release of information (CPP) Authorization for release of information (RRQ) Authorization for the collection and communication of personal information (disability) - 98185E02 Authorization for the release of information (personal information file) Authorization for the collection and communication of personal information (death) - 98185E03 Authorization for the release of information - CSST - 05172E Claim - Individual insurance - Accidental dismemberment or loss of sight, fracture - 0303101A Occupational status statement Disability - 10255E Claim - Total Long-Term Care - Independent Living - Loss of Independance Coverage Claim for benefits following an accident Occupational status statement Loss of employment benefits - 10256E Claim for loss of employment benefits Claimant's statement Death Claim - 98069E01 Critical illness claim form - Cancer, heart attack, stroke or other illness - Attending physician's statement - 1702601A Disability claim - Employer of self-employed individual's Statement Disability claim - individual Disabled person's Supplementary Statement Disability Physical Illnesses - RACQ - Additional report Physical Illnesses - RACQ - Original request Pre-Authorized debit agreement (PAD) Payor's authorization Form to be completed to authorize us to withdraw premiums related to your contract from your bank account. Critical illness claim form - Insured's statement - 1702504A Request for cancellation, policy loan, partial surrender or withdrawal of dividens Request for title changes Form to be completed to change the designation of policyowner or beneficiary. Reimbursement agreement for disability benefits overpaid by the insurer - 07147E01 Payor's authorization for pre-authorized debit (PAD) or credit card payment - 09311E Request for cancellation or partial withdrawal - 00101E13 Statement of good health - 00105E02 Insurability question number 2 on pre-existing conditions - 07043E Application for minor change - 09614A Changes to the savings fund of a Vision contract - 06252E Authorization to disclose medical information to the attending physician – 00103E06

Individual and Group Annuities
Quebec	Rest of Canada
Direct deposit enrolment - 99181E	Direct deposit enrolment - 99181E

Guaranteed Investment Funds
Quebec	Rest of Canada
Direct deposit enrolment - 99181E	Direct deposit enrolment - 99181E

Image - Need help? 1-866-838-7553

Legal Notice | Privacy Policy | Security | Consumer Information | Site Map

Cooperating in building the future

Individual insurance and savings

Group plans

Life events

Client services

For representatives

About us

All forms

Group Insurance - Claims

Medical Expenses

Quebec

Rest of Canada

Dental Expenses

Quebec

Rest of Canada

Travel Insurance

Quebec

Rest of Canada

Disability

Quebec

Rest of Canada

Prior Authorization Drugs

Quebec

Rest of Canada

Accidental Loss

Quebec

Rest of Canada

Death of Member or Dependent

Quebec

Rest of Canada

Others

Quebec

Rest of Canada

Group Insurance - Admin.

Quebec

Rest of Canada

Accident insurance

Quebec

Rest of Canada

Travel Insurance

Quebec

Rest of Canada

Change of address

Quebec

Rest of Canada

Life, health and disability insurance

Quebec

Rest of Canada

Individual and Group Annuities

Quebec

Rest of Canada

Guaranteed Investment Funds

Quebec

Rest of Canada