Forms for Group Benefits Plan Administrators

For Selectpac plans with 3 to 35 plan members

The following 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.

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.

Note: Many of the forms can be completed on screen, 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.

• Application for group coverage
  Use this form to submit information needed to enroll new plan members in a group benefits plan.

• Application Form M6108 - for plans administered by Great-West Life
• Application Form M6108(GN) - for plan administrators using GroupNet for Plan Administration, Great-West's online plan administration tool

• Employee Change form
  Use this form to update information about plan members and/or their dependants.

• Change Form M6109 - for plans administered by Great-West Life
• Change Form M6109(GN) - for plan administrators using GroupNet for Plan Administration, Great-West's online plan administration tool

• Group Insurance Adjustments M266(SEL) BIL
  Use this form to summarize new or updated information about plan members and/or dependants, and may require the Application for Group Coverage or Employee Change forms above to be attached. (Types of changes that apply are listed in the "Reason Codes" section on the form.)
   
  To find the CANUS Adjustments form (M5840 BIL) and other CANUS forms, go to the CANUS Forms for Plan Administrators page.
   
• Trustee Appointment M6242 BIL
  Use this form to designate a trustee for a beneficiary who is a minor or who is legally unable to manage their own affairs.
• Consent to Change of Irrevocable Beneficiary M6320 BIL
  Use this form to obtain consent for removal of a beneficiary that has been designated irrevocable.
• Irrevocable Beneficiary Designation M6348 BIL
  Use this form to designate a beneficiary as irrevocable.

• Application for Non-Smoker Rate
  Use the designated form to apply for a change from a smoker rate to a non-smoker rate.

• Application Form M4672 – for Optional Life and Optional Group Critical Illness plan members
• Application Form M4672A – for Solace plan members

• Evidence of Insurability

• Evidence of Insurability M6129
  Use this form to submit the plan member information needed to apply for group benefits which require medical underwriting, such as Optional Life, Excess Life and LTD, Supplemental Life and Late applicants.
• Evidence of Insurability M5995(CHOLIFE)
  Use this form to submit the information needed to apply for group benefits which require medical underwriting. Use this form instead of M6129 when your plan includes Child Optional Life.
• Evidence of Insurability - Critical Illness M5995(CI)
  Use this form to submit the plan member information needed to apply for Group Critical Illness coverage, which requires medical underwriting.

• Group Life Conversion

• Group Life Conversion Privilege Notification M5725(Quebec)
  For plan members living in Quebec, use this form to convert group life insurance to an individual life insurance policy.
• Group Life Conversion Privilege Notification M5725
  For plan members living outside of Quebec, use this form to convert group life insurance to an individual life insurance policy.
• Group Life Conversion Fact Sheet M6236
  Use this information sheet to provide plan members with details about individual life insurance policy conversion, eligibility and options.

• Group Life Claim Report M62
• Employer Life Waiver of Premium – Notice of Claim M642
• Application for Optional Group AD&D M6708
• Notice of Return to Work M403 BIL
  Use this form to submit information about a plan member who is returning to work after a short-term or long-term disability absence.
• Application for Group Short Term Disability Benefits – Employer's Statement M5453
• Application for Group Long Term Disability Benefits – Employer's Statement M4306
  Note: If the plan member is receiving short term disability benefits, it is not necessary to complete this form.
• Early Referral Services -- Employer's Statement M5469A BIL
• Supply Services Order Form M173(D52)
  Use this form to request a supply of any Great-West forms.