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 or her group insurance.

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 that can 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 The billed amount will automatically be withdrawn from your financial institution and submission of premium cheques will no longer be required.

Web@dmin Access - F54-788A		To authorize one or several administrators to have access to Web@dmin, our online tool, or to cancel Web@dmin access rights.

Individual Health Insurance ApplicationTRANSIT - F54-776A-2		To be completed by a member who wishes to continue benefiting from medical and dental coverage after the expiry date of his or her group insurance.


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 (fillable version) – F54-326A		For reimbursement of prescription drugs, paramedical or eye care, or ambulance transportation. Form that can be completed on screen.

Dental Care (fillable version) – F54-288A		For reimbursement of dental care. Form that can be completed on screen.

Health Spending Account (fillable version) - F54-780A		For reimbursement of expenses using your Health Spending Account. Form that can be completed on screen.

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 (fillable version)		For reimbursement of prescription drugs, paramedical or eye care, or ambulance transportation and/or reimbursement of expenses using your Health Spending Account.

Direct deposit of disability benefits - F54-072A		To allow plan members to request the direct deposit of their disability benefit payments in their bank account.

Prior Authorization Form for Drug Reimbursement (fillable version)		In order for us to evaluate the reimbursement request for a drug that requires prior authorization. The member must ask his/her doctor to fill out this form.

Prior Authorization Form for Xenical Reimbursement (fillable version)		In order for us to evaluate the reimbursement request for Xenical. The member must ask his/her doctor to fill out this form.