For plan administrators

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


Application for Enrolment – 9147A (PDF, 1.1 MB) Opens in a new window.

This form is used to apply for or reinstate a plan member’s coverages.

Important:

Depending on the coverages selected, the plan member may need to fill out other forms.


Policyholder's Request for Change – 9097A (PDF, 194 KB) Opens in a new window.

This form is used to advise us of any divisional changes, including:

  • salary change
  • return to work
  • termination of employment
  • disability
  • company address change
  • new plan administrator, etc.

Notice of Modification – 20017A (PDF, 91 KB) Opens in a new window.

This form is used to advise us of any change regarding plan members:

  • salary change
  • departure
  • return to work
  • disability

Request for Exemption or Application for Enrolment (Following the Termination of Exemption) – 02757A (PDF, 138 KB) Opens in a new window.

This form is for plan members who don’t want certain benefits because they already have similar coverage through another plan, or who want to re-enrol after having being exempted.


Member’s Change Request – 04035E (PDF, 699 KB) Opens in a new window.

This form is used to make the following policy changes:

  • change or cancel coverage
  • add optional benefits
  • request or terminate an exemption
  • add eligible dependants

Dependant’s Statement – 00291E (PDF, 179 KB) Opens in a new window.

This form is used to update information about a covered dependent or to add a new one.

Important:

Before you fill out this form, make sure your plan allows you to manage your own dependents. The maximum age to qualify as a dependent child varies from contract to contract. Check your contract to be sure!


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

This form is used to notify us that a plan member has returned to work following an absence.

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 – 00159E01 (PDF, 1.1 MB) Opens in a new window.

This form is used to notify us that a plan member has returned to work following an absence.

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.


Application for Enrolment Business Pre-Authorized Debits – Insured Benefits – 09240E (PDF, 1.2 MB) Opens in a new window.

This form is used by administrators to authorize monthly withdrawals to cover the premiums for insured benefits.

Important:

Include a VOID cheque with the form.


Application for Enrolment Business Pre-Authorized Debits – Administrative Services Only (ASO) – 09240E02 (PDF, 1.2 MB) Opens in a new window.

This form is used by administrators to authorize monthly withdrawals to cover the total amount of benefits paid and fees billed for self-insured benefits.

Important:

Include a VOID cheque with the form.


Application for Enrolment Business Pre-Authorized Debits – Insured Benefits and Budgeted Administrative Services Only Plans (BASO) – 09240E05 (PDF, 1.2 MB) Opens in a new window.

This form is used by administrators to authorize monthly withdrawals to cover the total appearing on the combined premium statement, which includes insured benefits and budgeted administrative services only plans (BASO).

Important:

Include a VOID cheque with the form.


Health and lifestyle questionnaire (Evidence of insurability) – 20009A (PDF, 408 KB) Opens in a new window.

This form is used to apply for enrolment in the group insurance plan, based on the contract provisions.

Important:

This form should only be filled out at Desjardins Insurance's request. This form is not used for dental care. Use form 20021A (PDF, 410 KB) Opens in a new window. for dental expenses. Sometimes we ask that an applicant be assessed by a healthcare professional before we make a decision.


Evidence of Insurability – Dental Care – 20021A (PDF, 410 KB) Opens in a new window.

This form is used to apply for enrolment in the dental care insurance plan, based on the contract provisions.

Important:

This form should only be filled out at Desjardins Insurance's request. This form is used for dental care only. Use form 20009A (PDF, 408 KB) Opens in a new window. for all other applications for enrolment.


Evidence of Insurability – Critical Illness – 98140E (PDF, 1.2 MB) Opens in a new window.

This form is used to apply for critical illness insurance, based on the contract provisions.

Important:

Sometimes we ask that an applicant be assessed by a healthcare professional before we make a decision.


Form for evidence of insurability – Requested benefits – 17100E (PDF, 1.06 MB) Opens in a new window.

To be filled out by administrators of self-administered or TED groups and attached to the evidence of insurability.


Request for forms – 9155A (PDF, 109 KB) Opens in a new window.

This form is used to order extra hard-copy forms.


Cost Plus Claim – 14302E

For a claim submitted on an exceptional basis, for medical or dental expenses that aren’t covered by your group insurance plan or your administrative only (ASO) plan.

Cost Plus Claim – Quebec (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – Ontario (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – NewFoundland and Labrador (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – Alberta (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – Manitoba (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – Saskatchewan (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – British Columbia (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – New Brunswick (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – Nova Scotia (PDF, 1.5 MB) Opens in a new window.

Cost Plus Claim – Prince Edward Island (PDF, 1.5 MB) Opens in a new window.