CLAIM FORMS HOMEPAGE
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- Short Term Disability EmployEE Statement
- ATTENDING PHYSICIAN STATEMENT
- Short Term Disability EmployER Statement
These benefits are available to eligible employees and provide salary replacement (wage-loss) benefits for specified periods of time, to employees who are disabled due to injury or sickness. Once the applicable documents have been completed in full, please return them to the Benefits Administration Office.
NOTE: Please ATTACH a copy of your employee’s JOB DESCRIPTION together with the Employer Statement. This will help GWL in assessing the employee’s ability to return to work.
Mandatory for all eligible CISVA employees, Critical illness insurance alleviates some of the stress due to financial burden when an insured is diagnosed with a covered condition. In the occasion of a Critical Illness claim, please forward this completed document directly to the Benefits Administration Office. There are additional documents (including an Employer claim form) that need to accompany this attachment. Therefore, do not forward this claim directly to the Claims Department as indicated on the claim form.
- Life Claim Brochure
- Life Claim (Beneficiary) Form
- Life Claim Form Employer Statement (To be completed by the Benefits Administration Office)
Mandatory for all eligible CISVA employees, Basic Group Life provides benefits to your designated beneficiary in the event of your death, for whatever cause. Spouses and dependent children are not covered under this plan In the occasion of a Life claim (including an Optional Life claim), please forward this completed document directly to the Benefits Administration Office. There are additional documents that need to accompany this attachment. Therefore, do not forward this claim directly to the Group Life Benefits Department as indicated on the claim form.
Accidental Death & Dismemberment (AD&D)Mandatory for all eligible CISVA employees, Accidental Death and Dismemberment (AD&D) coverage provides benefits should you be a victim of an accident that costs your life, limb, sight or hearing. In the occasion of an AD&D claim, please contact the Benefits Administration Office for the applicable form.
- Notice of death claimant’s form in fillable Word format
- Notice of death claimant’s form
In the occasion that a member of the CISVA Registered Pension Plan dies, the attached document must be completed by the beneficiary and sent directly to the Benefits Administration Office. There are additional documents that need to accompany this attachment. Therefore, do not forward this claim directly to Great-West life, Group Retirement Services as indicated at the top of the claim form. Once this step has been completed, Great-West life, Group Retirement Services will contact the beneficiary to provide a summary of available options.
Extended Health Care covers you for some charges arising from physician-recommended and medically necessary services and supplies, beyond the scope of MSP. Even if you or your dependents are already enrolled under your spouse?s plan, you may also enroll in the CISVA plan, provided the other plan allows double coverage. Please refer to the Enrollment forms section should you wish to add/remove dependents from your current coverage (complete a Group Coverage Change form).
The Assure Card is an electronic payment system that provides on-the-spot claims submission of prescription drug claims at almost any pharmacy in Canada. It?s a convenient, easy-to-use alternative to submitting claim forms. Plan members continue to pay 100% of the drug costs upfront; however, you simply present your Assure Card when having prescriptions filled. The pharmacist uses the card to confirm eligibility, drug coverage and remit your eligible drug claim directly to Assure for processing.
- Out-of-Country claim
- MSP Out-of-Country claim
- Authorization to provide medical info Schedule B
- Assignment of payment Schedule A
- Instructions on how to complete the Out-of-Country claim form
Submit all out-of-province/country claims to Great-West Life using the Out-of-Country claim form. Great-West Life will coordinate payment of your claim with MSP.
The Welcome Plan is a temporary supplementary group plan of insurance which provides essential basic healthcare coverage for temporary, new and returning Canadian residents and their family when they do not qualify for provincial health plan coverage in their province or territory. Welcome Plan benefits are available as long as the employee meets all eligibility requirements. To be eligible under the Welcome Plan the employee must be covered under the Extended Health plan, they must legally reside in a Canadian province or territory, and must not be eligible for coverage under a federal or provincial government health plan (ie: MSP) because they do not satisfy the residency requirement in their province or territory of residence.
The Dental Care plan provides coverage for a wide range of dental services, from your regular check-ups to major procedures such as root canals and crowns. Even if you, your spouse or dependent children are already enrolled under your spouse?s plan, you may also enroll in the CISVA plan, provided the other plan allows double coverage. Please refer to the Enrollment forms section should you wish to add/remove dependents from your current coverage (complete a Group Coverage Change form).