To Order Forms

Here you will find all the claims forms, administrative forms and return envelopes that you require. You may download them in PDF format or order paper copies.

Claims – Forms and Return Envelopes

F54-326A	Medical and Paramedical Expenses	PDF (177.37 kB)
F54-288A	Dental Care	PDF (172.92 kB)
F54-383A	Health Spending Account (HSA)	PDF (247.61 kB)
F54-069A	Direct Deposit for medical expenses and dental Care	PDF (191.85 kB)
F54-381A	Disability – Initial Request	PDF (670.29 kB)
F54-382A	Disability – Extension of disability	PDF (2.45 MB)
F54-907A	Disability – Policyholder’s statement	PDF (247.79 kB)
F54-072A	Direct Deposit for disability benefits	PDF (191.23 kB)
F54-996A	Travel Insurance (emergency medical care)	PDF (107.39 kB)
F54-361A	Life Insurance	PDF (138.68 kB)
F54-856A	Critical Illness	PDF (1.2 MB)
F54-380A	Accidental Dismemberment	PDF (181.81 kB)
F54-267A	Dental Care in case of an accident	PDF (154.66 kB)
F54-859A	Prior Authorization Drug form	PDF (228.96 kB)
F54-835A	Request for brand name drug exception	PDF (85.68 kB)

Return envelopes

N° de formulaire	Nom	Commander
F48-182A	Disability Claims - Montréal
F48-184A	Health and Dental Claims- Montréal
F48-184A-1	Health and Dental Claims- Toronto
F48-184A-2	Disability Claims - Toronto

Administration – Forms and Return Envelopes

F54-018A	Enrolment Request	PDF (261.4 kB)
F54-018A-1	Enrolment Request – with online beneficiary designation	PDF (440.91 kB)
F54-070A	Change Request	PDF (302.56 kB)
F54-070A-1	Change Request – with online beneficiary designation	PDF (306.31 kB)
F54-002A	Evidence of Insurability	PDF (654.87 kB)
F54-863A	Policyholder Pre-Authorized Debit Agreement (PAD)	PDF (154.02 kB)
F54-1021A	Notice Of Administrative Changes	PDF (150.39 kB)
F54-776A-2	Transit - Individual Health Insurance Application	PDF (661.2 kB)
F54-848A	Transit - Brochure	PDF (307.25 kB)
No number	Transit – Rates Table	PDF (147.36 kB)
F54-030A	Conversion request – Group life insurance (regular groups)	PDF (112.18 kB)
F54-030-1A	Conversion request – Group life insurance (self-administered groups or third-party administrators)	PDF (114.94 kB)
F54-833A	Request for Extension of Benefits	PDF (305.65 kB)
F54-020A	Notice of Change	PDF (176.84 kB)

RETURN ENVELOPES

N° de formulaire	Nom	Commander
F48-182A	Administration department - Montréal
F48-182A-1	Administration department - Toronto
F48-184A-3	Accounting department - Toronto

Other forms

Don't see the form you need in the list above? Please enter the name or number of the form you need in the box below and we'll send it to you.

To expedite processing of your request, please include the complete information required (for example, Manager’s Assistance Program, F54-761A, quantity: 50).

Delivery Information

Recipient

Contact Person

First name

Last name

Shipping address

Name of your enterprise or group

Number

Street

Bureau (facultatif)

City

Postal Code

Telephone

Poste (facultatif)

Back

Consult the Administration Guide to facilitate the administration of your group insurance plan.

Administration guide (1.18 MB)

Billing Schedule

For 2023 payment deadlines and statement dates, please consult this calendar.