Given the current situation and the possibility of delays in postal services, we encourage you to use our online services.
If you have to send us a paper form, please send it, along with any accompanying information or receipts, via our secure forms submission page rather than by mail.
Instructions
- Fill out and sign the form
- Gather the required supporting documents
- 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 Enrollment – 9147A (PDF, 1.6 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, 1.5 MB) 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, 212 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, 1.5 MB) 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 Change Request – 04035E (PDF, 1.2 MB) 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, 1.5 MB) 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 Enrollment Business Pre-authorized Debits – Group insurance – 09240E (PDF, 1.4 MB) Opens in a new window.
This form is used by administrators to authorize monthly withdrawals to cover the amount indicated on the billing statement sent by Desjardins Insurance.
Important :
Include a VOID cheque with the form.
Health and lifestyle questionnaire (Evidence of insurability) – 20009A (PDF, 2.6 MB) 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, 1.9 MB) Opens in a new window. for all other applications for enrolment.
Form for evidence of insurability – Requested benefits – 17100E (PDF, 1.4 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, 1.4 MB) 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.