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. 

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) 


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)

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)
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