Administrative forms
Find the group insurance form you need and submit it online or by mail.
How to submit a form
- Fill out and sign the form.
- Gather any required supporting documents.
- Send everything online or by mail (address listed on the form).
Good to know
Originals will not be returned, so keep copies of all correspondence for at least 12 months.
Forms
Application for enrollment or reinstatement
Depending on the coverage selected, the employee may need to fill out other forms.
Policyholder request for change
To advise us of the following changes:
- Salary change
- Return to work
- Termination of employment
- Disability
- Name change
- Division change
- Class change
- Address change
- New plan administrator
Notice of modification
To advise us of any change regarding plan members:
- Salary change
- Departure
- Return to work
- Disability
Request for exemption or application for re-enrollment
For plan members who want to:
- Opt out of benefits because they have similar coverage through another plan
- Re-enroll after having been exempted
Plan member change request
For plan members who want to make the following changes:
- Change or cancel coverage
- Add optional benefits
- Request or terminate an exemption
- Add eligible dependants
Dependant's statement
If a member's plan allows them to manage dependant information, they can use this form to:
- Update information about a covered dependant
- Add a new dependant
Notice of return to work
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 employee returns to work.
Business pre-authorized debits (PAD) – Application for enrollment
Evidence of insurability (health and lifestyle)
This form should only be filled out at our request.
Sometimes we ask that an applicant be assessed by a healthcare professional before we make a decision.
Evidence of insurability (dental care)
This form should only be filled out at our request.
Sometimes we ask that an applicant be assessed by a healthcare professional before we make a decision.
Evidence of insurability (self-administered plans and TED)
To be filled out by administrators of self-administered groups and groups using TED (transfer of electronic data) and attached to the evidence of insurability.
Request for forms
This form is used to order extra hard-copy forms.
Cost Plus claim
For a claim submitted on an exceptional basis for medical or dental expenses not covered by your group insurance plan or administrative only (ASO) plan.
Contact us
Customer service
Monday to Friday: 8 AM to 8 PM (Eastern Time)
1-800-463-7843 Phone number for group insurance customer service. This link opens your phone app.
Group insurance products are manufactured by Desjardins Financial Security Life Assurance Company.