Menu
Health, dental and disability claim forms

Health, dental and disability claim forms

1 1 1 1 1 1 (1 Review)

All claim forms open in Adobe Reader. If you do not have Adobe Reader, you can download it free of charge here:
get Adobe Reader

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

Health and dental insurance

Extended health care benefits
This form is used for health care benefits, such as medical or paramedical expenses, drugs and 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
This form is used for dental claims. In most cases, your dentist will be able to submit claims automatically through an electronic data interchange (EDI) system.

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, and 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 must be provided with the Attending Physician’s Statement. Both are required for any claims related to an accidental fracture.
Critical illness
The Claimant's Statement, Attending Physician’s Statement and Medical Certificate are required for any claims 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 health care.

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

Disability insurance – Initial claim

Claimant's guide to disability insurance
This guide provides information and forms to help you file the initial claim for disability benefits and/or waiver of premiums.

Important: Your claim must be submitted to the insurer within 90 days of the onset of disability.

Business expenses report for overhead expenses
This form is required to file a claim for the overhead expenses benefit. You must also provide all supporting documents for each of your expenses.

Because your overhead expenses claim is related to a sick leave, you must complete the claim forms for disability benefits, which are included in the claimant's guide to disability insurance. If your claim is related to the overhead expenses benefit only, you don't need to provide proof of income.

Note that since changes in expenses may occur during a disability period, supporting documents may be requested regularly during your leave.

Mortgage Plan - Information on the creditor/loan
This form is required if you file a claim for Mortgage Plan; you must also provide proof of the last payments made to the creditor.

Because your Mortgage Plan claim is related to a leave of absence, you must complete the claim forms for disability benefits, which are included in the claimant's guide to disability insurance. If your claim is related to Mortgage Plan benefit only, you don't need to provide proof of income.

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

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.

Disability insurance – Claims during a disability period

Authorization forms
This authorization allows the insurer to obtain information that is necessary to assess your claim. Use this form if you are asked for a recently signed, original authorization.
Return to work notice
This form is required to confirm your 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 submitted with this form.
Accident statement
This form may be required if the description of the accident given on the Claimant’s Statement and included in the initial claim is considered incomplete.
Business expenses report for overhead expenses
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 a copy to be completed. The form may also be used if the insured person is disabled again after attempting to return to work. In this case, the employer must complete the form again.
Attending physician's statement – additional report
If your disability leave has been extended, this form must be completed by your attending physician or specialist. Updated clinical notes and the last medical reports must be attached.
Request for payment by direct deposit
Use this form if you did not choose direct deposit as the method of payment on your initial claim. Simply complete the 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.