Claim Forms

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The standard versions of claims and administration forms used by Manulife Financial Group Benefits are posted here.

For SecureServe Clients only
Access your custom forms by clicking here.

Claim Forms:

Extended Health Claim Form
Print, complete and submit this form to claim the eligible extended health care benefits costs covered under your Manulife Financial Group Benefits plan, which may include:
  • drug and other medical expenses (e.g. medical supplies);
  • equipment and appliances;
  • vision care expenses; and
  • practitioner expenses.

Dental Care Claim Form
Most dentists provide plan members with a standard Canadian Dental Association (CDA) claim form. If the dentist does not provide a CDA form, please print, complete and submit this form to claim the eligible dental care benefits costs covered under your plan.

Administration Forms:

Request for Over-Age Dependent Coverage
Continued coverage for full-time students, beyond the age specified in your group benefits plan, can be requested by printing, completing and submitting this form to Manulife Financial Group Benefits. This form must be re-submitted by July 31st each year to confirm over-age student status coverage is continuing for the next school year. Coverage will then be extended up to August 31st of the next school year, the upper limit of the dependent definition age, or until coverage is terminated.

Request for Over-Age Disabled Dependant Coverage
Continued coverage for children with disabilities, beyond the age specified in your group benefits plan, can be requested using this form.

Request for Conversion Information
Plan members are able to continue all or part of their Group Life Insurance coverage when it reduces or terminates, by converting to an Individual Policy. Complete and submit this request form to obtain full details of the conversion privilege as well as a premium quotation.

Group Benefits Materials Re-order form
Please print, complete, and mail or fax this form to order a supply of claim and/or administration forms.

Plan Administrator quick reference guide
When you call the Group Benefits Customer Service Centre on your touchtone phone, press a few numbers and connect quickly to the answers you need. Just print one of these quick reference guides and keep it handy for reference.

Enrolment Forms:

Enrolment or Re-enrolment Application
The enrolment form should be completed on an employee's date of hire or re-hire and must be signed no later than 31 days after the employee's first day of eligibility.

Evidence of Insurability

Amounts of Life and Long Term Disability Insurance are available without providing medical evidence of good health up to certain limits. These limits are referred to as Non-Evidence Limits.

Employees should complete this form when:
  • they must provide medical evidence of their insurability as a condition of enroling in the plan,
  • they first apply for an amount of insurance over the Non-Evidence Limit,
  • as a plan member, they later apply for additional amounts of insurance over the Non-Evidence Limit,
  • they are late applying for their coverage, and therefore considered a Late Applicant, or
  • they re-apply for insurance on any person whose application for insurance had previously been declined.

Refusal of All Coverage

If participation in your group is
not mandatory, employees may choose not to join. If employees choose not to join, they must print, complete this form and submit it to their plan administrator. If the group is Manulife Financial Administered, the plan administrator must forward the original copy to Manulife Financial Group Benefits.

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