e-Member Services 
 

Health, Dental and Disability Claim Forms

 

You can access our claim forms online. Click on the link related to the form you need. The form will open in a new browser window to be printed. If more than one form is required to file a claim, the forms will be printed one after another (health claims form can be completed online).

Important
Claims filed for heal care costs or disability benefits must be sent to the insurer within a certain period of time. This information is available in the Claimant's Statement. If the claim is not sent within the appropriate period of time, it could be refused by the insurer.

Authorization of the insured

(to collect medical information)

Authorization(s)
Health insurance

This document includes three (3) authorizations required for any claim related to healthcare fees. The authorization allows the insurer to collect medical information pertinent to analyse a claim. If the authorizations are not attached to the claim, processing and reimbursement of fees could be delayed.

Important: The three authorizations must be signed and dated by the claimant. 

Health Insurance

Extended Health Care Benefits Claim Form

This form is used for health care benefits such as medical or paramedical expenses, drugs or vision care.

Complete this form online, save it, print and sign it, and mail it to us along with your original receipts. 

Important: claims must be submitted no later than 12 months after expenses are incurred.

Hospital Allowance
Or
Daily indemnity

The Claimant's Statement is provided with the Hospitalization Certificate. Both are required for any claim under one of the following benefits : Hospitalization, Hospital Allowance or Daily Indemnity. They may also be used to claim ambulance transportation expenses.

Important: The Hospitalization Certificate must be completed by an authorized agent.

Dental Care Claim Form

This form is used for dental claims. In most cases, your dentist will be able to submit claims automatically through a system called EDI (electronic data interchange).

If your dentist has EDI, you'll just need to provide your policy and ID numbers. Your dentist will electronically submit your claim to us. We'll mail you or your dentist a reimbursement cheque for any eligible expenses.

If your dentist does not have EDI, please submit the completed and signed dental claim form provided to you by your dentist.

Accidental Fracture

 

The Claimant's Statement is provided with the Attending Physician Statement. Both are required for any claim related to an accidental fracture.

Critial Illness

 

The Claimant's Statement, Attending Physician Statement and Medical Certificate that are required for any claim filed for medical care costs related to a critical illness covered by the contract.

Important: The Medical Certificate must be completed by an authorized agent if the insured received out-patient treatments or home healthcare.

Accidental Loss of Use and Dismemberment

 

The Claimant's Statement and Attending Physician Statement are required for any claim related to accidental loss of use or accidental dismemberment.

Disability Insurance (Initial Claim)

Claimant's Guide - Disability Insurance

This guide provides information and forms to help you file the initial claim for disability benefits and/or waiver of premiums. The Guide also answers to frequently asked questions (FAQ).

Important: your claim must be submitted to the Insurer within 90 days of the onset of disability.

Overhead Expenses Claim Form - Business Expenses Report

This form is required if you file a claim for Overhead Expenses benefit. You must also provide all supporting documents for each of your expenses.

Your overhead expenses claim being related to a sick leave, you must complete the claim forms for Disability benefits. You will find all of those forms in the Claimant's Guide - Disability Insurance. If your claim is related to Overhead Expenses benefit only, you don't need to provide a proof of income.

Please note that supporting documents may be requested regularly during your sick leave since change in expenses may occur during a disability period.

Mortgage Plan - Information on the creditor/loan

This form is required if you file a claim for Mortgage Plan; you must also provide proofs of the last payments made to the creditor.

Your Mortgage Plan claim being related to a leave of absence, you must complete the claim forms for Disability benefits. You will find all of those forms in the  Claimant's Guide - Disability Insurance. If your claim is related to Mortgage Plan benefit only, you don't need to provide a proof of income. 

In case of variable interest, some changes may have occurred in the payments to the creditor. Please note that supporting documentation may be requested regularly during your disability period.

Please be advised that the direct deposit option is not authorized in the case of claims related to a mortgage loan or any other type of loan.

Forms to be completed during a disability period

Authorization(s) Disability Insurance

This authorization allows the insurer to obtain information that is necessary to continue the assessment of your claim. They might be required from time to time since public organisations are asking for recently signed original authorizations.

Return to Work Notice

This form is required to confirm the date of return to work and to reinstate the automatic benefit increase option on coverage that would have been suspended during the work stoppage. A medical certificate specifying the date of return must be attached to this form.

Accident Statement

This form may be required if the description of the accident given in the Claimant’s Statement form and included in the initial claim is considered incomplete.

Business Expenses Report

This report is necessary when a claim is filed under the Overhead Expenses benefit.
Expense reports and supporting documents are regularly requested during a period of disability. Generally, this information is required every three months as we must ensure that current expenses are equal to the insured amount. 

Employer's Statement

If the insured person has more than one employer, this form may be used to provide them with a copy to be completed. It may also be used if after an attempted return to work, the insured person is disabled again. In this case, the employer must complete the form once again.

Attending Physician's Statement - Additional Report

If the disability has been extended, this form must be completed by your attending physician or specialist. Updated clinical notes must be attached as well as the last medical reports in order to avoid any delays in the processing of your claim. 

Request for payment by direct deposit

If this method of payment was not chosen on the initial claim, it is possible to request it at any time as long as the insurance file is active. Simply complete this form and attach a VOID cheque. Please note that this method of payment is not available if you file a loan or mortgage claim as payments are made directly to your creditor.


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