Forms & Resources
Here you'll find everything you need to manage your employee benefit plan. These forms do change from time to time, so bookmark this page for future reference. That way you’ll always be sure to have the most current versions.
Enrolment/Administration
Here's everything you need to manage your employees in the Chamber of Commerce Group Insurance Plan.
- Administration Supply Request Form
- Application for Over-Age Disabled Dependent Coverage
- Application to Insure a Dependent who is Over Age 21
- Beneficiary Designation
- Employee Application
- Employee Change Request
- Employee Statement of Dependent Health
- Employee Statement of Health
- Firm Contact and Address Change Form
- Group Benefit Plan Waiver
- Group Insurance Benefit Change Form
- Group Life Insurance Conversion Waiver
- Intent to Convert Accidental Death & Dismemberment Coverage
- Intent to Convert Group Life Insurance Coverage
- National Formulary
- Optional Life Insurance Application
- Request for Pre-Authorized Payment Plan (Note: For direct deposit of claim payments, see below.)
- Salary Change Request
- Statement of Income Worksheet
Claims
Should you ever need to submit a claim, you’ll find your forms here.
- Claim Supply Request Form
- Cost Plus Reimbursement
- Dental Accident Claim
- Dental Claim
- Direct Deposit of Health & Dental Benefit Payments
- Employee Reimbursement Form for ASSURE Drug Claims
- Extended Health Claim
- Life / Accidental Death & Dismemberment Claim | * Please call (info below)
- Long Term Disability Claim | * Please call (info below)
- Short Term Disability Claim | * Please call (info below)
- Voyage Assistance
Resources
Employee Introduction
Use this letter to introduce the Chambers Plan to your employees.
Group Benefit Plan Waiver
If an employee declines to participate in the Plan, we recommend they complete this waiver, which you can save in your files.
Group Life Insurance Conversion Waiver
If an employee leaves your company, use this waiver when they don't want to convert their group life insurance to an individual policy. Save it in your files for future reference.
Intent to Convert Group Life Insurance Coverage
If a departing employee would like to convert life coverage, please send in this notice promptly so that we can get the application to the employee. Desjardins Financial Security must receive the completed application and first premium within 31 days of the date the employee leaves your firm.
*Please contact the Service Centre for help submitting this type of claim. The information we need may vary so please contact a service representative so we can help speed the process for you.
Call 1-800-665-3365
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“Forms are readily available online and claims are handled quickly which is such a bonus to the staff.”