Group Forms

All forms are in Acrobat PDF format, and will open in a new window using Adobe Reader. If you do not have Adobe Reader installed, you can install it for free here.

Enrollment Forms

Group Benefits Enrollment forms are used to enroll employees into the group insurance plan. The enrollment form should be completed and signed by the employee no later than 31 days after the date the employee first becomes eligible for insurance coverage.

Most policies require all eligible employees to join the group insurance plan. These policies are considered Mandatory Participation plans. Policies that provide employees with an option to join the group insurance plan are Voluntary Participation plans.

Please select the appropriate Group Benefits Enrollment Form from the list below:

• Group Benefits Enrollment Form (Compulsory Participation)
• Group Benefits Enrollment Form (Voluntary Participation)
• Dependent Child Eligibility Form
• Group Alternate Coverage Information Form
• Diversity Basic & Enhanced Employee Application

Individual Applications/Health Questionnaires

Completion of an individual application gathers personal health information on an applicant in order to determine if the person is eligible for insurance or eligible for higher amounts of insurance.

• Completion of the Late Application for Group Insurance form is required when an eligible employee does not join the group plan within 31 days of first becoming eligible.
• Completion of the Application for Excess Life, LTD and STD Group Insurance form is required when a group member is eligible for insurance that is greater than the non-evidence limit.
• Completion of the Individual Application for Optional Group Life Insurance is required if an eligible employee wants to add this coverage to their group benefits. As not all Group Insurance Policies offer this benefit, please check your employee booklet for this coverage before submitting an application.
• Completion of the Tobacco Usage Questionnaire is required if an insured member wishes to change their smoker status currently on file with Wawanesa Life. This change is only applicable to those persons with Optional Life Insurance under the group policy.
• Upon termination of insurance with Wawanesa Life, the insured member may be eligible to convert their Group Life insurance. Completion of the Conversion of Group Life Insurance is required to convert Group Life insurance
• Diversity Basic & Enhanced Health Statement

Change Forms

The Change Form can be used to change a group member's name or marital status, add or remove dependents covered under the plan, refuse health and/or dental benefits, and to refuse all benefits under a voluntary plan. To change a beneficiary on a group insurance plan, the Change of Beneficiary Form should be used.

• Notice of Change Form
• Change of Beneficiary Form

Claim Forms

Life Claims

• Group Death Claim
• Proof of Death

Critical Illness

All Claimants must complete a Claimant's Statement form as well as the attending Physician must complete the specific illness statement form.

• Claimant's Statement - All Illnesses
• Alzheimer's Disease - Physician Statement
• Blindness - Physician Statement
• Cancer - Physician Statement
• Coronary Artery Bypass Surgery - Physician Statement
• Failure of Both Kidneys - Physician Statement
• Heart Attack - Physician Statement
• Organ Transplant - Physician Statement
• Multiple Sclerosis - Physician Statement
• Parkinson's Disease - Physician Statement
• Stroke - Physician Statement

Disability Claims

• Disability Claim Form

Health Claims

• Extended Health and Vision
• Extended Health and Vision with Health Spending Account
• Out of Country

In provinces where the Provincial Health Plan provides for drug coverage, please visit the applicable Provincial Website for application forms to register for your provincial deductible.

Dental Claims

• Dental
• Dental with Health Spending Account

 

Toutes les formes sont dans le format de l'Acrobat PDF, et s'ouvriront dans une nouvelle fenêtre en utilisant Adobe Reader. Si vous ne faites pas installer Adobe Reader, vous pouvez l'installer gratuitement ici.