Claim and administration
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
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 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!
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
| 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) |
| 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) |
| 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) |
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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) |
| 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) |
| 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) |
| 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 |
