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 Enrolment Business Pre-Authorized Debits – Insured Benefits – 09240E (PDF, 1.4 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, 1.4 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, 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.