Claim and administration
Simple, efficient and user-friendly!
File your claims in the Client Centre and get reimbursed faster.
3 quick ways to submit your claim
For medical and paramedical care, including prescription drugs, dental care and vision care
Online
Access the electronic claim form in your Client Centre or on the La Capitale website and submit your claims
On the La Capitale
mobile app
You can submit your claim by adding photos of your receipts
Directly on site
Present your service card at your healthcare professional's office. They will process your claim for you!
Are you part of a public administration group?
Consult the forms and information regarding your group.
General forms
Medical, paramedical and dental care
Administration
Disability
|
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 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 insurance claim form Download (PDF - 2 pages) |
| These forms must be signed and sent by your employer. |
| Group insurance application / Modifications to group insurance Download (PDF - 2 pages) |
| Group insurance application / Modifications to group insurance / Advantage 2-9 Download (PDF - 2 pages) |
| Age 65 - Reimbursement of prescription drugs by Insurer Download (PDF - 1 page) |
| Termination of exemption Download (PDF - 1 page) |
| These forms must be sent to the email address indicated on the form or by mail. |
| Designation of beneficiary Download (PDF - 1 page) |
| Information concerning dependents Download (PDF - 1 page) |
| Dependent child status for a person with a total disability or functional impairment Download (PDF - 2 pages) |
| Preauthorized debit agreement (PAD) Download (PDF - 1 page) |
| Authorization - Revocation for the disclosure of personal information Download (PDF - 1 page) |
| Evidence of Insurability Download (PDF - 2 pages) |
| Status statement smoker or non-smoker Download (PDF - 1 page) |
| Declaration of insurability / Dental care insurance plan / Group insurance Download (PDF - 1 page) |
| Declaration of the claimant Download (PDF - 1 page) | Send by email to collectif_deces@lacapitale.com or by mail |
| Healthcare Insurance Application (Perspective 3992) Download (PDF - 2 pages) |
| For Group Insurance |
| Application for short and/or long term Disability Insurance Benefits / Initial Application Download (PDF - 4 pages) |
| Application for extension short and/or long term / Disability Insurance Download (PDF - 4 pages) |
| Application for direct deposit of benefits Download (PDF - 1 page) |
| 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 |
Contact us 1 800 463-4856
Monday to Thursday 8:30 a.m. to 8:00 p.m.
Friday 8:30 a.m. to 5 p.m.
Saturday 9 a.m. to 12 p.m.
Holiday Schedule
