Standard Claim Forms

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.

Healthcare and Dentalcare Forms

• Dentalcare Claim Form M445D BIL
  How to complete this form
• Healthcare Claim Form M635D BIL
  How to complete this form
• Visioncare Claim Form M1214D BIL
  How to complete this form
• Nursing Care Health Assessment Form E1083A

• Find out more about nursing care coverage in our Nursing Care Coverage brochure. [PDF]

• Assure Card Claim Forms (Prescription Drug Card Claim Form for plan members with an Assure Card)
  Choose the form that corresponds to the office where you normally send your healthcare claims.

• If you send your claims to London, Montreal, Toronto or Winnipeg, use M6226 BIL
• If you send your claims to Regina, use M6226(R) BIL

Disability Forms

• 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 Forms

• 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