Forms & Documents

The following forms are available in Adobe Acrobat format. To download this free software, visit the Adobe Website

Health Association Forms must be printed duplex (back-to-back) and on the paper size specified. We have noted the paper size to be used in brackets after the title of each form. 

Your compliance is required to ensure that plan member forms are accurate and complete, and meet specifications for electronic document management. 

Forms received that do not meet these specifications may result in processing delays, and if necessary, may result in us having to return forms to you. 

For more information please click here

 

Application and change forms

Application Form – Permanent Employees – Group Insurance Benefits (Form 1 – Letter)

Application Form – Temporary Employees – Group Insurance Benefits (Form 1T – Letter)

Application Form – LTD Only – Group Insurance Benefits (Form1LTD – Letter)

Application for Excess Amounts-LTD (Form 50 - Letter)

Benefit Change/Cancellation Form - Group Insurance Benefits (Form 7 - Legal)

Personal Information Change Form - Group Insurance Benefits (Form 61 - Legal)

Beneficiary Designation Form - Group Insurance Benefits (Form 62 - Legal)

path Referral (Form 38 - Letter)

Application for Continuation of Benefits During a Maternity/Pregnancy, Parental, Adoption Leave (Form 76 - Legal)

Application for Continuation of Group Benefits During an Approved Unpaid Leave of Absence (Form 12 - Legal)

Application for Continuation of Group Benefits During an Unpaid Leave of Absence Due to an Injury or Sickness (Form 48 - Legal)

Application for Continuation of Group Benefits - Retired Members (Form 17 - Letter)

Application for Continuation of Group Benefits - Retired Members (Form 17LT - Letter)

Application for Continuation of Group Benefits health only - Retired Members (Form 2 - Letter)

LTD Approval - Benefits Election Form (Form 65 - Letter)

LTD Insurance Plan Monthly Remittance Form (Form 44 - Complete form & mail copies as instructed on form)

Overage Dependent Form (Form 56 - Letter)

Manulife Evidence of Insurability Form - Health (Statement of Health) (Form B1 - Letter)

Manulife Evidence of Insurability Form – Optional Life (Form B1 – Letter)

Manulife Application for Over-Age Disabled Dependent Coverage (Form 55 - Letter)

Manulife Direct Deposit Form (Form 66 - Letter)

Manulife Evidence of Insurability Form - Critical Illness (Form 57 - Letter)

Retiree Change Form - Group Insurance Benefits (Form 74 - Letter)

PAP Form - Group Insurance Benefits (Form 11 - Letter)

Plan Sponsor Request to Continue Group Coverage (Form 69 - Letter)

SSQ Accidental Death & Dismemberment Conversion Notice (Form 40 - Letter)

SSQ Emergency Travel Card (Letter)

Forms Notes and Comments – Employer Form (Form 78) (Letter)

 

Claim forms  

SSQ Emergency Medical Claim Report - Out of Province or Out of Country and Consent to Collect Form (Form 45 – Letter)

Critical Illness Notification Form (Form 49 - Letter)

Manulife Group Benefits Extended Health Care Claim Form (Form 67 - Letter)

Manulife Group Benefits Dental Claim Form (Form 42 - Letter)

Manulife Group Benefits Vision Claim Form (Form 51 - Letter)

Manulife Clinical Measurements Claim Form (Form 53 - Letter)

Optional Accidental Death & Dismemberment Claim Form (Form 39 - Legal)

 

Waiver Applications for Employees Not Covered Under the NSAHO LTD Plan

CI - Manulife Waiver of Premium Member Statement (Form 71 - Letter)

CI – Manulife Waiver of premium APS (Attending Physician's Statement) (Form 72 – Letter)

CI – Manulife waiver of premium plan sponsor statement (Employer) (Form 73 – Letter)


Long Term Disability Claim

LTD Application Package - Disabled After October 1, 2010 (Letter)