Industrial Alliance - Downloadable Forms

For accidental death or dismemberment cases, contact the Claims Department to obtain the appropriate forms:


Administration

Notice of Change – F54-020A		To indicate a new member or change information.

Request for Conversion – F54-030A		To be completed by a member who wishes to remain insured after the expiry date of his group insurance.

Enrolment Request – F54-018A		To enrol a new member to the group plan.

Change of record – F54-070A		To modify the member's personal information and/or benefits.

Enrolment Request (fillable version) – F54-018A		To enrol a new member to the group plan. Form to be completed on screen.

Request for extension of benefits – F54-833A		To request an extension of insurance when terminating an employee (e.g. in accordance with the employment standards act or a severance agreement).

Evidence of Insurability – F54-002A		To confirm a member's state of health. Required when the sum insured increases or when the member or one of the member's dependents enrols in the plan after the time period set out in the contract.

Order Form – F54-702A		To order administrative or claims forms.

Direct Deposit and E-Notification request - F54-069A		To allow plan members to request the direct deposit of their benefit payments in their bank account and to be notified by email of the status of their medical expense and/or dental claims.

Pre-Authorized Withdrawals form (F54-863A)		To allow you to pay your monthly bill by pre-authorized payment. The billed amount will automatically be withdrawn from your financial institution and submission of premium cheques will no longer be required.


Claims

Disability claim form- Initial request - F54-381A		To make the initial claim for the disability income benefit following a disability.

Disability claim form - Extension of Disability – F54-382A		To make a claim for the disability income benefit when the disability is extended beyond the initial period.

Life Insurance – F54-361A		To obtain the payment of life insurance following the death of a member or a dependent.

Medical Expenses – F54-326A		For reimbursement of prescription drugs, paramedical or eye care, or ambulance transportation.

Dental Care – F54-288A		For reimbursement of dental care.

Dental Care in Case of an Accident – F54-267A		For reimbursement of dental care when the expenses are incurred following an accident. This care is reimbursable under the health insurance coverage.

Health Spending Account - F54-780A		For reimbursement of expenses using your Health Spending Account.

Dental Care – Health Spending Account - F54-839A		For reimbursement of dental care and/or reimbursement of expenses using your Health Spending Account.

Medical Expenses – Health Spending Account - F54-840A		For reimbursement of prescription drugs, paramedical or eye care, or ambulance transportation and/or reimbursement of expenses using your Health Spending Account.