Forms for group insureds
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Your main group insurance forms are listed here. View and print the document you want by selecting it from the list.
| 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) |
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Claim for prescription drug and for medical and paramedical expenses Download (PDF - 2 pages) |
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Request for Brand Name Drug Coverage Download (PDF - 2 pages) |
| Request for Assessment Prior Authorization Drug Download (PDF - 2 pages) |
| Declaration of insurability / Dental care insurance plan / Group insurance Download (PDF - 1 page) |
| Dental insurance claim form Download (PDF - 2 pages) |
| 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) |
| Dependent child status for a person with a total disability or functional impairment Download (PDF - 2 pages) |
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Designation of beneficiary Download (PDF - 1 page) |
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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) |
| 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) |
| 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 |