Standard Claim Forms

Healthcare

• Healthcare Claim Form M635D BIL
  How to complete this form
• Healthcare Expenses Statement M635D(HCSA)
  For claims paid out of a base healthcare plan with the balance paid out of a Healthcare Spending Account plan.
• Healthcare Spending Account Plan (Healthcare) M5431A
  For claims paid out of a Healthcare Spending Account plan.
• Health SolutionsPlus M635D(HSPT)
  For more information on Health SolutionsPlus Visa® payment card, go to the Health SolutionsPlus page.
• Nursing Care Health Assessment Form E1083A
  Learn more about nursing care coverage.

Dentalcare

• Dentalcare Claim Form M445D BIL
  How to complete this form
• Healthcare Expenses Statement M445D(HCSA-W)
  For claims paid out of a base dentalcare plan with the balance paid out of a Healthcare Spending Account plan.
• Healthcare Spending Account Plan (Dentalcare) M5429A
• Health SolutionsPlus M445D(HSPT)
  For more information on Health SolutionsPlus Visa® payment card, go to the Health SolutionsPlus page.

Visioncare

• Visioncare Claim Form M1214D BIL
  How to complete this form

Prescription Drug Claims

These forms are for plan members with an Assure Card. Select the form that corresponds to the office where you normally send your healthcare claims:

• London, Montreal, Toronto, Winnipeg: Assure Card Claim Form M6226 BIL
• Regina: Assure Card Claim Form M6226(R) BIL

Disability

• Short Term Disability Income Benefits – Employee's Statement M5454
• Long Term Disability Income Benefits – Employee's Statement M4307B
• Early Referral Services – Employee's Statement M5469B

Life and AD&D

• Accidental Dismemberment or Specific Loss M4437
• Specific Loss Supplementary Benefits Claim Form M6710
• Certificate of Attending Physician M4442
• Life Waiver – Employee's Statement M4811
• Group Life Claim Report M62
• Attending Physician’s Certificate of Death M63
• Advance Payment Request – Attending Physician's Statement M5886 BIL
• Advance Payment Request – Employer's Statement M5885 BIL

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.