- Enrollment Forms
- Individual Applications/Health Questionnaires
- Change Forms
- Claim Forms
- Spending Accounts
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 – Employee Application
- Dependent Child Eligibility Form
- Dependent Student Eligibility Form
- Essentials 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 Application for Excess Coverage and Late Applicants form is required when an eligible employee does not join the group plan within 31 days of first becoming eligible, or 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. Please email us for details on how to convert Group Life insurance.
- Use this form to apply for With Evidence Long Term Disability coverage or for Employee/Spouse/Dependent late application. Essentials 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.
Claim Forms
Life Insurance Claims
Critical Illness
Critical Illness offers coverage for insured conditions and provides a benefit payable on the insured condition for which a diagnosis is made or surgery is performed. (Not all illnesses listed are covered in each contract. Specific Illness covered are provided within the Plan Sponsor's contract. Please consult your contract or contact us at 1-800-665-7076, option 3, should you have any questions regarding coverage).
All Claimants must complete a Claimant's Statement form as well as the attending Physician must complete the specific illness statement form.
Full Benefit Payout - Employee and Dependent Spouse:
- Dementia, including Alzheimer's Disease - Physician Statement
- Aortic Surgery - Physician Statement
- Aplastic Anemia - Physician Statement
- Bacterial Meningitis - Physician Statement
- Benign Brain Tumour - Physician Statement
- Blindness - Physician Statement
- Cancer - Physician Statement
- Cardiomyopathy - Physician Statement
- Coma - Physician Statement
- Coronary Artery Bypass Surgery - Physician Statement
- Deafness - Physician Statement
- Fulminant Viral Hepatitis - Physician Statement
- Failure of Both Kidneys - Physician Statement
- Heart Attack - Physician Statement
- Heart Valve Replacement - Physician Statement
- Loss of Independent Existence - Physician Statement
- Loss of Limbs - Physician Statement
- Loss of Speech - Physician Statement
- Major Organ Failure on Waiting List - Physician Statement
- Major Organ Transplant - Physician Statement
- Motor Neuron Disease - Physician Statement
- Multiple Sclerosis - Physician Statement
- Muscular Dystrophy - Physician Statement
- Occupational HIV - Physician Statement
- Paralysis - Physician Statement
- Parkinson's Disease - Physician Statement
- Primary Pulmonary Arterial Hypertension - Physician Statement
- Severe Burns - Physician Statement
- Stroke - Physician Statement
Partial Benefit Payout - Employee and Dependent Spouse:
- Coronary Angioplasty
- Ductal Breast Carcinoma In-situ
- Early Stage Chronic Lymphocytic Leukemia
- Early Stage Malignant Melanoma
- Early Stage Prostate Cancer
- Early Stage Thyroid Cancer
Full Benefit Payout - Dependent:
- Benign Brain Tumour
- Blindness
- Cancer (Life Threatening)
- Cerebral Palsy
- Coma
- Congenital Heart Defect
- Cystic Fibrosis
- Deafness
- Diabetes Type1
- Down Syndrome
- Kidney Failure
- Major Organ Failure on Waiting List
- Major Organ Transplant
- Muscular Dystrophy
- Severe Burns
- Paralysis
Disability Claims
The following three statements must be completed as a part of the claim for Disability Benefits:
- Plan Member Statement: completed by the Plan Member
- Plan Sponsor Statement: completed by the Plan Sponsor
- Attending Physician's Statement: completed by the Attending Physician
All claim forms must have the handwritten signature of the person responsible for completing the form.
Note: only submit Wavier of Premium claim forms if not submitting a claim for Short or Long Term Disability benefits.
Long Term Disability (LTD):
- Long Term Disability Checklist
- Plan Member Statement
- Plan Sponsor Statement
- Attending Physician Statement
Short Term Disability (STD):
- Short Term Disability Checklist
- Plan Member Statement
- Plan Sponsor Statement
- Attending Physician Statement
Waiver of Premium (WOP):
- Waiver of Premium Checklist
- Plan Member Statement
- Plan Sponsor Statement
- Attending Physician Statement
Supplementary Disability Forms:
Health Claims
Health Benefits for Plan Members and eligible Dependents are provided in conjunction with your Provincial Health Plan. With the exception of Emergency Out-Of-Country coverage and referral Out-Of-Country coverage (where applicable and included in the plan design), all medical services must be performed in Canada, and, medical equipment and supplies must be purchased in Canada.
In addition to the above, Wawanesa Life recommends that Plan Members refer to their Plan Member Booklet for additional information.
- Extended Health and Vision Claim Form
- Custom Foot Orthotics Claim Form
- Paramedical Services Claim Form
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
To help navigate you through our Plan Member Online Claims site to submit your health and dental claims, see our Plan Member Claims: Information Guide.
Spending Accounts
Health Care Spending Account
A Health Care Spending Account (HCSA) allows the Plan Member to submit for reimbursement of health and dental related expenses not reimbursed by their traditional benefit plan(s).
If you are currently eligible for benefits under 2 group plans, expenses must be claimed through both plans prior to submitting through HCSA.
For expenses to be eligible for reimbursement under the HCSA, the expenses must be defined in the Canada Revenue Agency's Medical Expense Tax Credit program. All HCSA reimbursements require the Plan Member to sign up for Electronic Fund Transfer (EFT) in the Plan Member Online Claims site.
Expenses can be submitted electronically (depending on the type of expense) using the Plan Member Online Claims site or on a paper claim form. Forms are available through the links below.
