Forms

You can download individual forms in PDF format:

Blue Cross Forms

Application Forms

• Application – Dental and Health (EN/FR)
• Application – Health (EN/FR)
• Application – For new hires when coverage not compulsory – Health/Dental (EN/FR)
• Application – For new hires when coverage not compulsory – Health (EN/FR)
• Application – Survivor Benefit for Actives
• Application – Retiree Health and Dental (EN/FR)
• Application – Retired WSD MGEU plan

Change Forms

• Blue Cross – Cancellation Request
• Blue Cross – Loss of Coverage Form
• Blue Cross – Notice of Change Form

Claim Forms

• Blue Cross – Health Benefits Claim Form
• Blue Cross – Dental Claim Form

Other Plan Forms

• Blue Cross – Glucose Monitoring – Special Authorization Request Form
• Blue Cross – Pre-Authorized Debit Application for Leave of Absence
• Blue Cross – Brochure for mybluecross
• Blue Cross – How to submit a claim in mybluecross

Canada Life Forms

Plan Forms

• MPS 103 – Change of Beneficiary and/or Appointment of Trustee
• MPS 301 – Application for Life Benefits (EN/FR)
• MPS 401 – Request to Increase or Reduce Coverage – Evidence of Insurability Not Required
• MPS 402 – Request to Increase Coverage – Evidence of Insurability Required
• MPS 403 – Selection of Payment Method on Approved Leave
• MPS 404 – Overdue Premium Letter
• MPS 405 – Application for Reinstatement of Coverage – Terminated Due to Non-Payment – Evidence Required

Insurer Forms

• CL M62(PS) – Group Life Claim Form for Employer (EN/FR)
• CL M62(CS) – Group Life Claim Form for Claimant (EN/FR)
• CL M63 – Attending Physician’s Certificate of Death
• CL M4437 – Group Life Claim Form for Accidental Dismemberment or Specific Loss
• CL M4442 – Group Life Claim Form for Attending Physician –  Dismemberment or Loss
• CL M6710 – Group Life Claim Form for Accidental Death,  Dismemberment & Specific Loss Supplementary Benefits
• CL M642 – Employer Statement – Waiver of Life Insurance Premiums (EN/FR)
• CL M4811ST – Employee Statement – Waiver of Life Insurance Premiums (EN/FR)
• CL M4811GD – Employee Statement Guide – Waiver of Life Insurance Premiums
• CL M4307B – Attending Physician’s Statement – Waiver of Life Insurance Premiums
• CL M5995 – Evidence of Insurability Form
• CL M5725 – Conversion Notification
• CL – Conversion Facts (EN/FR)
• CL M7450 – Over Age Dependent
• CL M7354 – Advance Payment Request Form
• Should I Convert My Group Life Insurance?
• Devrais-je transformer mon assurance-vie collective?