Directly to Us
You can use the following claim forms for manual submission of claims. If you have questions, please contact the Plan’s Service Centre at 1 800 665-3365 or email us at email@example.com.
Extended Health / Dental Claims / Health Spending Account
Health / Dental
All claims must be made within 12 months of the date of service and include original receipts.
- Extended Health Claims pdf
- Dental Claims pdf
- Dental Accident Claims pdf
- Employee Reimbursement Form for Drug Claims
If both you and your spouse have Health and or Dental coverage, you can send claims to both plans for maximum coverage. Send an adult claim to the patient's plan first, then to the spouse’s plan for any outstanding expenses. For children's claims, start with the plan of the parent born earlier in the calendar year.
Health Spending Account (HSA)
Use this form to claim eligible expenses up to the maximum allowed under the Health Spending Account (HSA) portion of your plan. If you would like to coordinate expenses between your group insurance plan and your Health Spending Account, please use the Extended Health / Dental Claim forms and check "YES" to the Health Spending Account question to have any balances covered under your HSA.
Travel Health Claims
Submit all travel claim expenses to the Plan using the Travel Health Claim form. Claim payments will be coordinated on your behalf with your provincial government plan.
If you need to make a disability claim, please contact our Service Centre for the appropriate forms. You must be totally disabled and under the regular care and attendance of a licensed physician. Completed forms should be sent to the Service Centre as soon as possible to avoid delays. Weekly Indemnity claims submitted more than 90 days after the onset of disability, and Long Term Disability claims submitted more than 150 days after the onset of disability, will be declined.
- Business Expense Statement
- Business Overhead Benefits Worksheet
- Declaration of the Attending Physician - Additional Report
- Disability or Waiver of Premium Claim - Employee Statement
- Disability or Waiver of Premium Claim - Employer Statement
- Direct Deposit Enrollment
- Employee’s Release of Disability Claim Information
- Initial Attending Physician's Statement
- Long Term Disability Claim Instructions
- Long Term Disability – Claimant’s Statement
- Long Term Disability Claim – Employer’s Statement
- Long Term Disability – Owner’s Statement
- Long Term Disability Claim – Physician’s / Specialist’s Statement
- Understanding Your Long Term Disability Claim
- Weekly Indemnity (Short Term Disability) Claim Guide
Critical Illness Claims
To claim Critical Illness Benefits, please contact our Service Centre. We must receive written notice of the claim no later than 30 days from the date the claim arose. Proof of Diagnosis forms will then be provided to you, which must be submitted within 90 days from the date of claim.
Life Insurance and Accidental Death & Dismemberment Claims
Life Insurance & Accidental Death & Dismemberment claims must be submitted within 90 days of the death or dismemberment. Contact our Service Centre for the appropriate forms.
- Authorization to Obtain Information (Claimant)
- Authorization to Obtain Information (Deceased)
- Chambers Plan Group Life, Dependent Life & Accidental Death & Dismemberment (AD&D) Claim Guide
- Critical Illness Benefit - Attending Physician's Statement
- Critical Illness Benefit - Claimant's Statement
- Critical Illness Benefit - Employer / Administrator Statement
- Death Claim
- Death Claim - Claimant's Statement
- Death Claim - Employer Statement
- Death Claim - Physician's Statement
- Declaration of Status for the Deceased Common-Law Spouse
- Direct Deposit Enrollment
- Foreign Death Questionnaire
- Living Benefits Application
- Living Benefits Application - Insured's Statement
- Proof of Accidental Death - Attending Physician's Statement
- Proof of Accidental Death - Claimant's Statement
- Proof of Accidental Death - Employer / Administrator Statement
- Proof of Loss / Dismemberment Claim - Attending Physician's Statement
- Proof of Loss / Dismemberment Claim - Claimant's Statement
Tips For Faster Claim Reimbursement
Long Term Disability
Understand the steps involved in making a disability claim, and what happens after you submit the claim.
Why wait for reimbursement cheques? Have your Chambers Plan reimbursements deposited directly to your bank account. Sign up for claim direct deposits on my-benefits, or download and submit a Direct Deposit of Health & Dental Benefit Payments form.
Download the my-benefits app
No matter where you travel, take your Chambers Plan wallet card or download the my-benefits app and store your card on your mobile device! If you have a medical emergency away from home, contact Voyage Assistance immediately at the emergency numbers found on the back of the card to receive benefits.