Group Benefits Plan Forms

Medical & Dental forms

Extended Health Care Form
Use this form for all medical expenses except dental

Medi-Passport (only for members with extended health care coverage)
This is to be used should the employee require medical services when traveling outside British Columbia.

Dental Claim Form
Use this form for dental claims

Notification of Member Fair Pharmacare Registration Number
This form is used to notify us of a Fair Pharmacare registration number. For complete details or to register for Fair Pharmacare, go to their website

Enrollment & Update forms

Enrollment Card
Use this form to enroll in the group plan

Change Card
Use this form to notify us of any changes or additions to your personal information

Health Questionnaire
This form to be completed for excess risk long term disability and late entrant employee situations

Beneficiary Designation Form
Use this form to designate or change your beneficiary

Student Confirmation Form
Use this form to identify dependents who are attending post secondary school full time but are still under 25, not married, and supported by you.

Disabled/Handicapped Child Form
This form is to be used when a member's handicapped child reaches age 21, is wholly dependent on the member and is not married.

Disability forms

Short Term, Member Statement Form
Use this form when making a short term disability claim. Must be accompanied by Plan Sponsor and Attending Physician statement forms

Short Term, Physician's Statement Form
Use this form when making a short term disability claim, to be completed by the attending physician and signed by member.

Administration Forms (Plan administrator use only. Requires authorized signature)

Earnings Change Form
Use this form to report an update in a member's earnings.

Termination Form
Use this form to advise when a member's employment is termination.

Employee Refusal Card
Use this form when a member does not wish to be included in your company's group plan.

Short Term, Sponsor Statement
This form is to be completed by the employer to notify us of a member's absence from work due to a disability. Please send this form to the ARA office as we must include the a claims certificate produced by our admin system to confirm the plan details to the insurance company.

Short Term, Job Description
Complete this form when a member is expected to be absent for four weeks or more.

Short Term, Return To Work
Use this form to advise us a member has returned to work.

Notice of Long Term Claim Form
Employers complete this form when there is reason to believe the member will qualify for long-term disability benefits and there is no short term disability coverage in place.

Insurance (EI) Premiums
If you are an employer who provides your employees with disability coverage for short-term illness or injury, you may be eligible for a reduction in your EI premium rate. Click Here