CANUS Forms for Group Benefits Plan Administrators

The following forms are for CANUS plans only. (CANUS plans cover U.S. residents who work for Canadian employers.)

These forms are for Plan Administrator use only. If you’re a group plan member looking for claim forms, go to the Group Plan Members > Forms page.

Note: Some of these forms can be completed onscreen, by clicking in the space provided for writing and typing in your information. After printing the completed form, you will need to add any required signatures and dates by hand before you submit the form.

These documents are in PDF format. To view and print them, you need Adobe Acrobat Reader Version 4.0 or higher, which you can download, at no cost, from the Adobe website.

Administration forms

• CANUS Employee Application M5764
  Use this form to submit information required to enroll new plan members in CANUS plans.
• CANUS Personal Health Statement (for late applicants and excess life insurance)
  Use this form for employees who apply for excess life insurance or decline, and then subsequently request life, short-term disability or long-term disability coverage.
  
  This form may be submitted with the CANUS Employee Application or the employee can send it directly to the address indicated on the form.
• CANUS Special Beneficiary Designation GA3434
  Use this form to designate multiple beneficiaries for a plan member.
• CANUS Group Insurance Adjustments M5840 BIL
  Use this form to summarize new or updated information about plan members and/or their dependants. This form may require the CANUS Employee Application, Employee Request for Change or Special Beneficiary Designation forms, available on this page, to be attached. (Types of changes that apply are listed in the “Reason Codes” section on this form.)
• CANUS Employee Request for Change GA16 (4/07)
  Use this form to request changes in coverage or coverage information for plan members.
• CANUS Request for Group Life Conversion Information (Note: this new Anthem Life form replaces the previous HRMP UT2208 form)
  Use this form to request information about converting group life insurance to an individual life insurance policy for the plan member.
• CANUS Forms Request M173(CANUS)
  Use this form to request a supply of any CANUS forms.

CANUS claim forms

To find CANUS claim forms, go to the Group Plan Members > Forms page.