Claim and administration

Formulaires pour les assurés

Contact us 1 800 463-4856

8:30 a.m. to 5:00 p.m. Monday to Friday
Holiday Schedule

3 quick ways to submit your claim

For medical and paramedical care, including prescription drugs, dental care and vision care

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Online 

Access the electronic claim form in your Client Centre or on the La Capitale website and submit your claims 

Go to the Client Centre

Access the electronic claim form

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On the La Capitale
mobile app

 You can submit your claim by adding photos of your receipts

Download the mobile app

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Directly at the pharmacy or the dentist's office 

Present your service card at the parmacy or your dentist's office. They will process your claim for you!

iconeformulaire.png Forms 

Print and complete the claim forms below then send them by mail and get reimbursed once they are processed

  • Medical and paramedical 

  • Dental care

  • Administration

  • Disability

Medical and paramedical
Application for direct deposit of benefits Download (PDF - 1 page)
Authorization for the disclosure of medical information Download (PDF - 1 page)
Claim for prescription drug and for medical, paramedical and dental care expenses   (Electronic Form)

Claim for prescription drug and for medical and paramedical expenses Download  (PDF - 2 pages)

Request for Brand Name Drug Coverage Download  (PDF - 2 pages)

Request for Assessment Prior Authorization Drug Download (PDF - 2 pages)

 

Dental care
Declaration of insurability / Dental care insurance plan / Group insurance Download (PDF - 1 page)
Dental insurance claim form Download (PDF - 2 pages) 
Claim for prestation drug and for medical, paramedical and dental care expenses (electronic form)

 

Administration
Age 65 - Reimbursement of prescription drugs by Insurer Download (PDF - 1 page)
Authorization - Revocation for the disclosure of personal information Download (PDF - 1 page)
Civil status statement Download (PDF - 1 page)
Declaration of Insurability Download (PDF - 2 pages)
Declaration of Insurability - Critical Illness Insurance Download (PDF - 2 pages)
Declaration of Insurability - Healthcare Insurance Application (Perspective 3992) Download (PDF - 2 pages)
Dependent child status for a person with a total disability or functional impairment Download (PDF - 2 pages)

Designation of beneficiary Download (PDF - 1 page)

Employees on leave or on light duties on the date group insurance comes into force Dowload (PDF - 2 pages)

Exemption / Application for exemption / Termination of exemption Download (PDF - 1 page)
Healthcare Insurance Application (Perspective 3992) Download (PDF - 2 pages) 
Information concerning dependents Download (PDF - 1 page)
Membership application to group insurance / Modifications to group insurance Download (PDF - 2 pages)
Membership application to group insurance / Modifications to group insurance / Advantage 2-9 Download (PDF - 2 pages)
Notice /Temporary work interruption / Return to work Download (PDF - 1 page)
Notice of modification Download (PDF - 1 page)
Preauthorized debit agreement (PAD) Download (PDF - 1 page)
Status statement smoker or non-smoker Download (PDF - 1 page)

 

Disability
For Group Insurance
Application for extension short and/or long term / Disability Insurance Download (PDF - 4 pages) 
Application for short and/or long term Disability Insurance Benefits / Initial Application Download (PDF - 4 pages)
For La Capitale Financial Security’s  customers of the Penncorp Series/Pillar Series’ products
I hold an individual La Capitale Financial Security disability insurance policy outside of Quebec