Representative’s Resource Library

Forms

Administration

Claim

Underwriting

Administration

• Authorization to collect personal information (PDF – 212 Ko)
• Cancellation Request (PDF – 190 Ko)
• Change of occupation (PDF – 112 Ko)
• Declaration of health(PDF – 739 Ko)
• Declaration of health short form – Reinstatement(PDF – 58 Ko)
• Declaration of health - Accident Only (Superior Program)(PDF – 161 Ko)
• Income sharing (PDF – 130 Ko)
• Legal change request(PDF – 71 Ko)
• Modification to the effective date of contract - Acci-Jet Program(PDF – 23 Ko)
• Need analysis(PDF – 61 Ko)
• Overhead Expense Insurance(PDF – 51 Ko)
• Overhead Expense Insurance for Farm Enterprises(PDF – 50 Ko)
• Overhead Expense Insurance for Truck Owners(PDF – 50 Ko)
• Pre-authorized Debit Agreement (PDF – 253 Ko)
• Reinstatement form Acci-Jet (PDF – 193 Ko)
• Reinstatement form Cancer Guard (PDF – 193 Ko)
• Reinstatement form Excel Hospitalization (PDF – 49 Ko)
• Reinstatement form Excel Life (PDF – 50 Ko)
• Trucker - Driver - Transport driver(PDF – 54 Ko)

Declaration of Understanding

• Declaration Arabic (PDF - 241 Ko)
• Declaration Filipino (PDF – 108 Ko)
• Declaration German (PDF - 112 Ko)
• Declaration Greek (PDF - 108 Ko)
• Declaration Hindi (PDF - 280 Ko)
• Declaration Italian (PDF – 110 Ko)
• Declaration Japanese (PDF – 345 Ko)
• Declaration Korean (PDF -  373 Ko)
• Declaration Mandarin simplified (PDF – 305 Ko)
• Declaration Mandarin traditional (PDF – 176 Ko)
• Declaration Polish (PDF – 109 Ko)
• Declaration Portuguese (PDF – 108 Ko)
• Declaration Punjabi (PDF – 384 Ko)
• Declaration Russian (PDF – 111 Ko)
• Declaration Spanish (PDF – 107 Ko)
• Declaration Tamil (PDF - 134 Ko)
• Declaration Thaï (PDF – 154 Ko)
• Declaration Turkish (PDF - 110 Ko)
• Declaration Vietnamese (PDF – 181 Ko)

Claim

• Procedures for filing a claim (PDF – 40 Ko)

Individual Insurance

Accident Health Insurance

• Accident Health Insurance Benefit (PDF – 23 Ko)

Acci7

• Claim form for Acci7 (PDF – 41 Ko)
• Claim form for Acci7 (Resident, other than Province of Quebec) (PDF – 41 Ko)

Acci-Jet Program

• Application for return of premium (PDF - 98 Ko)
• Authorization (PDF – 42 Ko)
• Determining the amount of the monthly benefit (PDF – 140 Ko)
• Eligibility rules for home-based workers (PDF - 1,2 MB)
• Occupational Classes (PDF - 506 Ko)
• Overhead Expenses Claim Form (PDF – 55 Ko)
• Statement by Attending Physician (PDF – 126 Ko)
• Statement of Attending Physician - Psychological Illnesses (PDF – 193 Ko)
• Statement of Claimant(PDF – 68 Ko)
• Statement of Claimant (Resident, other than Province of Quebec) (PDF – 68 Ko)
• Statement of Income and job description (PDF – 28 Ko)
• Statement of Return to Work (PDF – 133 Ko)

Accxel (in force only)

• Accidental Dismemberment and Loss of Signs (PDF – 206 Ko)
• Application for return of premium (PDF - 98 Ko)
• Authorization RAMQ (PDF – 52 Ko)
• Dental Claim Form (PDF – 365 Ko)
• Hospitalization Insurance Claim Form (PDF – 871 Ko)
• Attending Physician's Statement (PDF 87 Ko)
• Hospitalization Insurance Claim Form (Resident, other than Province of Quebec) (PDF – 871 Ko)
• Individual Insurance Claim & Proof of Death (PDF – 55.2 Ko)
• Medical Expenses and accident insurance claim (PDF – 743 Ko)
• Monthly Benefit Declaration of Disability (PDF – 580 Ko)
• Monthly Benefit Declaration of Disability (Resident, other than Province of Quebec) (PDF – 580 Ko)
• Overhead Expenses Claim Form (PDF – 55 Ko)
• Statement of Return to Work (PDF – 133 Ko)

Cancer Guard

• Application for return of premium (PDF - 98 Ko)
• Statement of Claimant and Attending Physician (PDF – 162 Ko)

Hospitalization Insurance

• Application for return of premium (PDF - 98 Ko)
• Claim form accident health insurance benefit (PDF – 29 Ko)
• Hospitalization Insurance Claim Form (PDF – 871 Ko)
• Attending Physician's Statement (PDF 87 Ko)

Life Insurance

• Authorization RAMQ (PDF – 59 Ko)
• Authorization to collect information (PDF – 48 Ko)
• Individual Insurance Claim & Proof of Death (PDF – 55 Ko)

Superior Program

• Application for return of premium (PDF - 98 Ko)
• Authorization (PDF – 42 Ko)
• Authorization RAMQ (PDF – 52 Ko)
• Determining the amount of the monthly benefit (PDF – 140 Ko)
• Eligibility rules for home-based workers (PDF - 1,2 MB)
• Occupational Classes (PDF - 506 Ko)
• Overhead Expenses Claim Form (PDF – 55 Ko)
• Overhead Expenses Claim Form - Eligible Vehicule Expenses (PDF – 55 Ko)
• Statement of Attending Physician (PDF – 83 Ko)
• Statement of Attending Physician - Psychological Illnesses (PDF – 193 Ko)
• Statement of Claimant (PDF – 68 Ko)
• Statement of Claimant (Resident, other than Province of Quebec) (PDF – 68 Ko)
• Statement of Income and job description (PDF – 28 Ko)
• Statement of Return to Work (PDF – 133 Ko)

Travel Insurance

• Claim Form (PDF – 27 Ko)
• Hospital and Medical Expenses(PDF – 44 Ko)
• Trip Cancellation(PDF – 100 Ko)

Universal Loan Insurance

• Application for return of premium (PDF - 98 Ko)
• Authorization (PDF – 42 Ko)
• Authorization RAMQ (PDF – 52 Ko)
• Eligibility rules for home-based workers (PDF - 1,2 MB)
• Form for Determining Benefit Amount (Including Rent) (PDF – 93 Ko)
• Form for Determining Benefit Amount (PDF – 92 Ko)
• Occupational Classes (PDF - 506 Ko)
• Statement to be made by Employer or by Insured if self-employed (PDF – 52 Ko)
• Statement to be made by Employer or by Insured if self-employed (Resident, other than Province of Quebec) (PDF – 100Ko)
• Statement of Attending Physician (PDF – 83 Ko)
• Statement of Attending Physician - Psychological Illnesses (PDF – 193 Ko)
• Statement of Claimant (PDF – 80 Ko)
• Statement of Claimant (Resident, other than Province of Quebec) (PDF – 80 Ko)
• Statement of Return to Work (PDF – 133 Ko)

MRA groups

• Accidental dismemberment and loss of signs (PDF – 214 Ko)
• Authorization (PDF – 104 Ko)
• Authorization for disclosure of information (PDF – 72 Ko)
• Death authorization (PDF – 319 Ko)
• Dependent's life insurance benefit claim and proof of death (PDF – 104 Ko)
• Life insurance benefit claim and proof of death (PDF – 108 Ko)
• Long-term disability insurance claim or request for waiver of premiums (PDF – 146 Ko)
• Overhead Expenses Claim Form (PDF – 55 Ko)
• Overhead Expenses Claim Form - Eligible Vehicule Expenses (PDF – 55 Ko)
• Statement to be made by employer or by Insured if self-employed (PDF – 96 Ko)
• Statement to be made by Employer or by Insured if self-employed (Resident, other than Province of Quebec) (PDF – 100Ko)
• Statement to be made by attending physician (PDF – 161 Ko)
• Statement of Attending Physician - Psychological Illnesses (PDF – 193 Ko)
• Statement of income and job description ($1,000 and -) (PDF – 96 Ko)
• Statement of income and job description ($1,000 and +) (PDF – 98 Ko)

Underwriting

• Authorization (PDF – 52 Ko)
• Aviation or Aerial Sports (PDF – 60 Ko)
• Back (PDF – 58 Ko)
• Bowel disorders (PDF – 57 Ko)
• Cardiovascular disorders (PDF – 57 Ko)
• Climbing or mountaineering (PDF – 56 Ko)
• Diabetes (PDF – 59 Ko)
• Digestive disorders (PDF – 58 Ko)
• Driving record (PDF – 57 Ko)
• Drug use (PDF – 56 Ko)
• Epilepsy (PDF – 57 Ko)
• Joints (PDF – 57 Ko)
• Motor sports (PDF – 56 Ko)
• Nervous disorders (PDF – 57 Ko)
• Out-of-country travel or stays (PDF – 57Ko)
• Preparing for your phone interview or paramedical exam (PDF - 104 Ko)
• Pulmonary disorders (PDF – 59 Ko)
• Request to change Smoker rate to Non-Smoker rate (PDF - 61 Ko)
• Request to change Smoker rate to Non-Smoker rate - Acces Life (PDF - 440 Ko)
• Request to change Smoker rate to Non-Smoker rate - CancerGuard (PDF - 166 Ko)
• Rider (PDF – 53 Ko)
• Trucker driver - Transport driver (PDF – 54 Ko)
• Underwater diving (PDF – 58 Ko)
• Urinary disorders (PDF – 58 Ko)