Claim For Disability Insurance printable pdf download

Claim For Disability Insurance

PROTECTED once completed

Claim for Disability Insurance

Employer’s Statement

Policy No. 12500-G

Part 1 asks for information on the employee’s employment and coverage status. This part must be completed by the Human Resources Officer or

Compensation Advisor.

Part 2 asks for information on the employee’s specific duties. This part must be completed by the employee’s immediate supervisor or manager.

Please attach a current work description.

Sun Life Assurance Company of Canada (referred to in this form as the “Insurer”) must receive this form, the Employee’s Statement and the Attending

Physician’s Statement to review this claim. Please complete this form in its entirety and submit it by fax ideally at least 8 weeks before the end of the

elimination period but no later than 90 days after the end of the elimination period in order to avoid delays. If a claim form is submitted later than 90 days after

the end of the elimination period, the employee may not be entitled to Disability Insurance Plan benefits if the delay impedes the Insurer’s ability to assess the

claim. See submission instructions at the end of the form.

To avoid overpayment, you must advise the Insurer immediately when the employee returns to work.

PART 1: EMPLOYMENT AND INSURANCE INFORMATION

(to be completed by the Human Resources Officer or Compensation

Advisor)

Employer Information

Department or Organization Name

Address (Street No. and Name, Suite No.)

City

Province

Postal Code

Telephone No.

Pay Office

Departmental Alpha Code

Paylist

Bargaining Unit Designator

Classification, Group and

(BUD) No.

Level

Employee Information

Name (First and Last) (Quebec residents: Use maiden name, if

Date of Birth

Proof of age required if aged

applicable.)

Male

(dd/mm/yy)

60 or over

Female

Yes

Address (Street No. and Name, Apartment or Suite No.)

City

Province

Postal Code

Home Telephone No.

Alternate Telephone No.

Pension No.

Certificate No.

CG-

Coverage Information

Last date of entry into the federal public service:

Day

Month

Year

Date Disability Insurance coverage became effective:

Day

Month

Year

Has this insurance coverage ever been terminated?

If yes, give date and reason, as well as date of reinstatement.

Yes

Month and year last Disability Insurance premium was

deducted:

Month:

Year:

TBS/SCT 330-303E (10/2014)

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Claim For Disability Insurance

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