Group Insurance Forms - Forms for group insureds

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!

General forms

Medical and paramedical care
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) List of drugs requiring prior authorization (PDF - 2 pages)

Dental care
Dental insurance claim form Download (PDF - 2 pages)

Enrolment or modification to you insurance
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)

Authorizations
Preauthorized debit agreement (PAD) Download (PDF - 1 page)
Authorization - Revocation for the disclosure of personal information Download (PDF - 1 page)

Declarations
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)

Death of an insured
Declaration of the claimant Download (PDF - 1 page) \| Send by email to collectif_deces@lacapitale.com or by mail Checklist for life insurance claims (PDF - 1 page)

Retirement
Healthcare Insurance Application (Perspective 3992) Download (PDF - 2 pages) Find out more on the Perspective healthcare insurance page

Disability
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