Accident / Disability

Instructions

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

Important

  • Keep copies of all correspondence for at least 12 months.
  • Originals will not be returned.

Forms


Disability or Waiver of Premium Claim – Employee Statement – Plan member – 06329E (PDF, 1.5 MB) Opens in a new window.

This form is used to submit a disability insurance claim or to apply for a waiver of premiums if the plan member is already receiving long-term disability benefits from another source.

Important:

The Employer Statement 08317E (PDF, 1.6 MB) Opens in a new window. and the Declaration of the attending physician - Initial request – Plan member – 02025A (PDF, 1 MB) Opens in a new window. must be submitted with this form. You must provide complete answers to all questions.

Disability or Waiver of Premium Claim – Employee Statement – Plan member – 06329E01 (PDF, 1.5 MB) Opens in a new window.

This form is used to submit a disability insurance claim or to apply for a waiver of premiums if the plan member is already receiving long-term disability benefits from another source.

Important:

The Employer Statement 08317E01 (PDF, 1.6 MB) Opens in a new window. and the Initial attending physician's statement –12900E01 (PDF, 1.3 MB) Opens in a new window. must be submitted with this form. You must provide complete answers to all questions.


Disability or Waiver of Premium Claim – Employer Statement – Plan administrator - 08317E (PDF, 1.6 MB) Opens in a new window.

This form is filled out by the employer when a plan member submits a short- or long-term disability insurance claim or applies for a waiver of premiums.

Important:

The Employee Statement 06329E (PDF, 1.5 MB) Opens in a new window. and the Declaration of the attending physician - Initial request – Plan member – 02025A (PDF, 1 MB) Opens in a new window. must be submitted with this form. You must provide complete answers to all questions.

Disability or Waiver of Premium Claim – Employer Statement – Plan administrator - 08317E01 (PDF, 1.6 MB) Opens in a new window.

This form is filled out by the employer when a plan member submits a short- or long-term disability insurance claim or applies for a waiver of premiums.

Important:

The Employee Statement 06329E01 (PDF, 1.5 MB) Opens in a new window. and the Initial attending physician's statement – 12900E01 (PDF, 1.3 MB) Opens in a new window. must be submitted with this form. You must provide complete answers to all questions.


Declaration of the attending physician - Initial request – Plan member – 02025A (PDF, 1 MB) Opens in a new window.

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 (PDF, 855 KB) Opens in a new window.. The plan member is responsible for any fees charged for filling out the form.

Initial attending physician's statement – 12900E01 (PDF, 1.3 MB) Opens in a new window.

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 0202601A (PDF, 856 KB) Opens in a new window.. The plan member is responsible for any fees charged for filling out the form.


Declaration of the attending physician – Additional Report – Plan member – 02026A (PDF, 874 KB) Opens in a new window.

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

Important:

The plan member is responsible for any fees charged for filling out the form.

Declaration of the attending physician – Additional Report – Plan member – 0202601A (PDF, 872 KB) Opens in a new window.

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

Important:

The plan member is responsible for any fees charged for filling out the form.


Claim for Convalescent Care – Plan member - 98130E (PDF, 385 KB) Opens in a new window.

This form is used to submit a claim for homecare services if this coverage is offered under your policy.

Important:

One section of the form is filled out by the physician who recommended the convalescence period and another by health professionals consulted during the convalescence. The plan member is responsible for any fees charged for filling out the form.


Notice of Return to Work – Plan administrator– 00159E (PDF, 1 MB) Opens in a new window.

This form is filled out by the employer when an employee returns to work after receiving disability benefits.

Important:

This form must be completed and returned to us as soon as the return-to-work date has been confirmed or, at the latest, on the day the plan member returns to work.

Notice of Return to Work – Plan administrator– 00159E01 (PDF, 1 MB) Opens in a new window.

This form is filled out by the employer when an employee returns to work after receiving disability benefits.

Important:

This form must be completed and returned to us as soon as the return-to-work date has been confirmed or, at the latest, on the day the plan member returns to work.


Accidental Dismemberment or Loss of Sight Claim Form – Plan member – 02809A (PDF, 718 KB) Opens in a new window.

This form is used to submit a claim for:

  • accidental dismemberment
  • loss of sight
  • loss of function

Important:

One section of this form is filled out by the attending physician. Fees charged for this statement are to be paid by the insured.

Provide the Claim – Employer’s Statement 12123E (PDF, 196 KB) Opens in a new window. along with this form.


Claim – Employer’s Statement – Plan administrator - 12123E (PDF, 196 KB) Opens in a new window.

This form is filled out by the employer when an insured submits an accidental dismemberment or loss of sight claim or a critical illness claim.

Important:

This form must be submitted with the Accidental Dismemberment or Loss of Sight Claim Form – Plan member – 02809A (PDF, 718 KB) Opens in a new window. or with the Critical Illness Claim Form – Insured’s Statement 170252A (PDF, 127 KB) Opens in a new window.. We cannot settle the claim unless all questions are answered adequately.


Critical Illness Claim Form – Insured’s Statement – Plan member – 170252A (PDF, 127 KB) Opens in a new window.

This form is used to submit a critical illness claim if this coverage is offered under your policy.

Important:

This form must be submitted with the Claim – Employer’s Statement 12123E (PDF, 196 KB) Opens in a new window. and the Critical Illness Claim Form – Attending physician’s statement 17026A (PDF, 114 KB) Opens in a new window..


Critical Illness Claim Form – Attending Physician’s Statement – 17026A (PDF, 114 KB) Opens in a new window.

This form must be completed by both the attending physician and the insured and submitted with Critical Illness Claim Form – Insured’s Statement 170252A (PDF, 127 KB) Opens in a new window..

Important:

Fees charged for this statement are to be paid by the insured.


Reimbursement agreement for disability benefits overpaid by the insurer – 02352E (PDF, 733 KB) Opens in a new window.

To be completed by the insured as an agreement to reimburse Desjardins Insurance for any disability benefit overpayment resulting from the approval of a claim submitted to one or more government organization and subject to the group contract provisions.

Reimbursement agreement for disability benefits overpaid by the insurer – 02352E01 (PDF, 733 KB) Opens in a new window.

To be completed by the insured as an agreement to reimburse Desjardins Insurance for any disability benefit overpayment resulting from the approval of a claim submitted to one or more government organization and subject to the group contract provisions.