Forms

You can download individual forms in PDF format:

Blue Cross Forms

Application Forms

• Application – Dental and Health
• Application – Dental and Health (French)
• Application – Health
• Application – Health (French)
• Application – For new hires when coverage not compulsory – Health/Dental
• Application – For new hires when coverage not compulsory – Health/Dental (French)
• Application – For new hires when coverage not compulsory – Health
• Application – For new hires when coverage not compulsory – Health (French)
• Application – Survivor Benefit for Actives
• Application – Retiree Health and Dental
• Application – Retiree Health and Dental (French)
• Application – Retired WANTE plan

Change Forms

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

Claim Forms

• Blue Cross – Health/Vision 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

• MPS 103 – Change of Beneficiary and/or Appointment of Trustee
• MPS 301 – Application for Benefits
  • • English/French
• MPS 401 – Request to Increase or Reduce Coverage – Evidence Not Required
• MPS 402 – Request to Increase Coverage – Evidence 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
• CL M62(PS) – Group Life Claim Form for Employer
• CL M62(PS) – Group Life Claim Form for Employer (French)
• CL M62(CS) – Group Life Claim Form for Claimant
• CL M62(CS) – Group Life Claim Form for Claimant (French)
• CL M63 – Attending Physician’s Certificate of Death
• CL M4437 – Accidental Dismemberment or Specific Loss Claim Form
• CL M4442 – Certificate of Attending Physician Dismemberment or Loss
• CL M6710 – Accidental Death Dismemberment & Specific Loss Claim Form
• CL M642 – Employer Statement – Life Waiver of Premium
• CL M642 – Employer Statement –  Life Waiver of Premium (French)
• CL M4811 – Employee Statement – Life Waiver of Premium
• CL M4811 – Employee Statement – Life Waiver of Premium (French)
• CL M4811 – Employee Statement Guide – Life Waiver of Premium
• CL M4307 – Attending Physician’s Statement – Life Waiver of Premium
• CL M5995 – Evidence of Insurability Form
• CL M5725 – Conversion Notification
• CL – Conversion Facts
• CL – Conversion Facts (French)
• 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?
• Life Claim Guide