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Order Form - Online
For Plan Sponsor Use Only

1920 College Avenue, Regina, SK, S4P 1C4

Date Ordered: Monday, July 24, 2017

Group #: Acct #:

Company Name:

Contact's Name:

Address:

City:

Province:

Postal Code: # of Insured:

Phone: ()- Fax: ()-

E-mail:

Number
Required
Form # Description


GL2233 A Guide to Claiming Disability Benefits & Application for Group Long Term Disability Benefits (Employee Statement)


GL2236 A Guide to Claiming Disability Benefits and Application for Group Short Term Disability (Employer Statement)


GL1346 Accidental Dismemberment Claim Form


GL2234 Application for Group Long Term Disability Benefits - Employer Statement


GL2235 Application for Group Long Term Disability Benefits - Physician's Statement


GL2237 Application for Group Short Term Disability Benefits - Employee Statement


GL2238 Application for Group Short Term Disability Benefits - Physician's Statement


GL1643 Critical Disease Claim Form


LC231 Dental Claim Form


GL2050 Direct Deposit Application - Disability Benefit Payments


GL1989 Direct Deposit Application - Health Care/Dental Payments


GL1842 Disease Dismemberment Claim Form


GL1800 Early Intervention Services Application


GL1821 Early Intervention Services - Employee Authorization


LC241 Extended Health Claim Form


GL1364 Health Evidence Questionnaire


GL1444 Living Assistance Application


GL111 Notice of Death - Employer & Beneficiary's Statement


GL1726 Optional Accidental Death & Dismemberment Insurance Application


GL1953 Optional Group Life Insurance Application


GL2260 Plan Member Change Form


GL122 Plan Member Enrolment Form


GL263 Policy Change Form


GL1243 Pre-Authorized Debit Plan Application


GL1601 Proof of Death - Physician's Statement


LC278 Return to Work Notice


GL1905 Student Eligibility Form


Employee Benefit Booklets
(please select document type)
Booklets are shipped separately

Electronic file E-mail as above OR


Paper Booklets Quantity Required


Class of Booklets


GL1337 (01/11)


Note: When your order is submitted, a confirmation will be sent to your e-mail address at the top of this page.




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