• Assure Claim Form – Prescription Drugs Claim ONLY

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.

• Basic and Voluntary Critical Illness Claimants Statement 

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.

• Dental
• Instructions on how to complete the Dental claim form

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 plan, you may also enroll in the CISVA plan, provided the other plan allows double coverage.Please refer to the Enrollment formssection should you wish to add/remove dependents from your current coverage (complete a Group Coverage Change form).

• Short Term Disability EmployEE Statement
• Short Term Disability EmployER Statement
• ATTENDING PHYSICIAN STATEMENT

If the employee is claiming for a COVID-19 STD benefit, please fill out this form. The employer still needs to complete the Employer Statement.

• Short Term Disability COVID-19 CLAIM

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 email them to the Benefits Administration Office. ORIGINAL copy is not required anymore.

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.

• Extended Health
• Instructions on how to complete the Extended Health claim form

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 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).

• Life Claim Brochure
• Life Claim (Beneficiary) Form
• Life Claim Form EmployerStatement (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.

• 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.

• 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.

• Welcome Plan Claim Form

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.