Province of Quebec
Please inform us of any changes to a member's coverage as soon as possible so as to keep the premium statement and the member's coverage up to date.
We recommend that you keep copies of all correspondence for your files.
Please send us your duly completed forms at the address below:
Desjardins Financial Security
200 rue des Commandeurs
Lévis, Quebec G6V 6R2
Note: When you see the annotation "E-Form" beside some of the PDF below, this means you can fill out this form electronically, then print it, sign it, include original receipts and submit it by mail.
Application for Enrolment - 9147A
2 pages - 562 kb E-Form
Form to be completed by all new members or for reinstatement of Group insurance coverage.
Employer's Request for Change - 9097A
2 pages - 270 kb E-Form
Use this form to notify us of several changes of salary, returns to work, terminations of employment or disability, etc. or to inform us of any change in billing address, claims cheques, mailing address or change of employer's representative.
Member's Change Request - 04035E
1 page - 150kb E-Form
Plan members use this form to change or cancel their coverages, add optional benefits or to request or terminate an exemption, or to add eligible dependent(s).
Notice of Modification - 20017A
1 page - 49 kb
Use this form to advise us of a change in earnings or work status, or if an insured becomes disabled.
Request for Designation or Change of Beneficiary(ies) or Trustee - 20007A
1 page - 90 kb E-Form
Form to be completed when an insured wishes to change an irrevocable beneficiary, designate or add a new beneficiary or trustee. It is important that the insured return the original form and keep a copy.
Evidence of Insurability - 20009A
2 pages - 279 kb E-Form
This form must be completed in accordance with your contract provisions, except for dental care insurance (must be printed - front & back - on legal size paper 8½ x 14). Insureds must return the original and keep a copy.
Evidence of Insurability - Dental Care - 20021A
2 pages - 208 kb E-Form
This form must be completed in accordance with your contract provisions (must be printed - front & back - on legal size paper 8½ x 14). Insureds must return the original and keep a copy.
Preparing for a Nurse's Visit - 07072E
2 pages - 209 kb
Pamphlet designed for the benefit of plan members whose insurance application may require additional information.
Request for Exemption or Application for Enrolment
(Following the Termination of Exemption) - 02757A
1 page - 262 kb E-Form
This form should be used when an insured already has similar coverage under another plan or applies for coverage which has previously been waived.
Dependent's Statement - 00291E
1 page - 79 kb E-Form
If you have positive enrolment, use this form to enter a dependent or change information regarding a dependent already registered.
Questionnaire on Smoking Habits - 02754A
1 page - 60 kb E-Form
Insureds or spouses, who wish to take advantage of non-smoker rates, if applicable, must fill out this form.
Request for Forms - 9155A
1 page - 128 kb
When you require additional forms.
Change of Address or Employer's Representative - 9247A
1 page - 43 kb
To advise the insurer of any address changes in billing, correspondence, mailing of cheques or change of plan administrator.
Pre-authorized Debit of Group Insurance Premiums for Policyholder
or Employer - 8425G
1 page - 73 kb E-Form
To fill out when you wish to authorize us to withdraw the payment required for your group insurance plan premiums from your bank account. A voided specimen cheque must be attached.