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Plan Member Forms
Claim Form
Use this form to claim for medical, vision and extended health expenses and services.
Assignment of Benefits Form
Use this form for direct billing. Submit a completed and signed form along with receipts.
Plan Member Change Form
Use this form to request a change in your address, coverage, name, dependants or spouse.
Electronic Payment Authorization Form
Use this form to authorize payment for claims directly to your bank account via electronic fund transfer.
Over-age Dependant Form
Use this form to apply to extend a dependant’s coverage for age 21 and older. Provide a proof of enrolment at an accredited post-secondary institution.
Disabled Dependant Form
Use this form to apply for coverage for a disabled dependant once they reach age 21.
Change of Beneficiary Form
Use this form to register a change in your beneficiary.
Healthcare Provider Forms
Provider EFT Form
Use this form to set up an electronic fund transfers for claim payments (for providers only).
Assignment of Benefits Form
Use this form for direct billing. Submit a completed and signed form along with receipts.
Provider Electronic Claims Agreement
Fill out, sign and submit this Agreement to apply for online claims submission. This Agreement does not apply to pharmacists or dentists.
Plan Admin Forms
Plan Member Enrolment Form
Use this form to enrol a new Plan Member. A scan of completed forms must be submitted to your plan advisor.
Beneficiary Form
Use this form to designate a beneficiary.