Get your Group Benefits forms
Below, you’ll find our most used Group Benefits forms organized by product. If the form you need does not appear below, you can find it by logging on to Benefits Now®. Please download all the necessary forms to meet your needs and note that some forms are for the plan member, while others are for the plan sponsor or treating physician.
The forms on this page are for administrative and claims purposes, and in most cases will include instructions and the address to send them to.
How to use and submit forms
Save the forms to your computer. In some cases, you can fill them in directly before printing. Otherwise, print them out and complete them by hand before mailing to the address indicated on each form.
Administration forms
| Direct Deposit Application - Health Care/Dental Payments | Download  |
| Direct Deposit Application - Disability Benefit Payments | Download |
| Health Evidence Questionnaire | Download |
| Optional Accidental Death and Dismemberment Insurance Application | Download |
| Optional Critical Illness Insurance Application | Download |
| Optional Group Life Insurance Application | Download |
| Plan Member Enrolment Form | Download |
| Smoking Status Declaration | Download |
| Student Eligibility Form | Download |
Extended Health and Dental Claim forms
| Extended Health Claim forms | |
|---|---|
| Extended Health Claim Form | Download |
| Drugs – Prior Authorization List of Drugs | |
|---|---|
| If you have been prescribed one of the listed drugs, have your prescribing physician complete the appropriate form and submit to The Co-operators. Any costs incurred for the completion of pre-authorization request forms are the responsibility of the patient/plan member. | View drug list |
| Dental Claim forms | |
|---|---|
| Dental Claim form | Download |
| Long Term Disabilty | |
|---|---|
| Employer's Guide to Disability Claims | Download |
| Return to Work Notice | Download |
| Attending Physician Statement | Download  |
| Attending Physician Statement for Mental Health Conditions | Download |
| Plan Member Guide and Application | Download |
| Plan Sponsor Statement | Download |
| Rehabilitation Earnings Statement | Download |
| Short Term Disability | |
|---|---|
| Employer's Guide to Disability Claims | Download |
| Return to Work Notice | Download |
| Attending Physician Statement | Download |
| Attending Physician Statement for Mental Health Conditions | Download |
| Plan Member Guide and Application | Download |
| Plan Sponsor Statement | Download |
| Rehabilitation Earnings Statement | Download |
| Living Assistance | |
|---|---|
| Living Assistance® Benefit - Plan Member Agreement and Application | Download |
| Physician's Statement | |
|---|---|
| Alzheimer's Disease/Dementia | Download |
| Aortic Surgery, Coronary Angioplasty, Heart Valve Repair/Replacement | Download |
| Aplastic Anemia | Download |
| Bacterial Meningitis | Download |
| Benign Brain Tumor | Download |
| Blindness or Deafness | Download |
| Burns | Download |
| Cancer | Download |
| Coma | Download |
| Coronary Angioplasty | Download |
| Kidney Failure (End Stage Renal Disease) | Download |
| Life-Threatening Cancer | Download |
| Loss of Independent Existence | Download |
| Loss of Limbs | Download |
| Loss of Speech | Download |
| Major Organ Transplant & Major Organ Failure on Waiting List | Download |
| Motor Neuron Disease/Multiple Sclerosis | Download |
| Myocardial Infarction (Heart Attack) | Download |
| Occupational HIV Infection | Download |
| Paralysis | Download |
| Parkinson's Disease | Download |
| Stroke or Cerebrovascular Accident (CVA) | Download |