Desjardins Financial Security

Canadian Provinces and Territories with the Exception of Quebec

So that we may process your claims as quickly as possible, please:

Fill out the required forms in full;
Enter your group number and your insurance certificate number;
Enclose the necessary original documents.

Please send us your duly completed form to the following address:

P.O. Box 4358, STN A

Toronto ON M5W 3M3

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.

Medical Expenses

Medical Expenses (Drugs and other medical services, vision care)

Claim for Health Care Benefits - 1913201A
2 pages - 250 kb E-Form
Use this form to claim drugs, services provided by a health professional, or paramedical or vision care. Claims must be submitted no later than one year following the date expenses were incurred.

Authorization Request - Drug or Patient Exceptions - 01313E01
1 page - 45 kb
Use this form to claim exception drug requiring prior authorization.

Travel Insurance - Medical expenses incurred while outside your province of residence

Hospital and Medical Expenses Claim Form - Quebec Residents Only - 156381A
2 pages - 265 kb E-Form
Form to speed up the reimbursement of expenses incurred outside Quebec to insureds and service and care providers. Also authorizes the insurer to act on the insured's behalf in submitting claims to the RAMQ. Proof must be provided with the claim.

Claim Form - Medical Authorization - 155411A
2 pages - 104 kb E-Form
Form to be filled out by the attending physician when required by the insurer.

Dental Expenses

Claim Form for Dental Care Expenses - 1911001A
2 pages - 153 kb E-Form
This form should be used to submit a dental claim.

Disability Benefits

Disability Claim - 98124E01
2 pages - 345 kb E-Form
This form should be used to submit a short term or long term disability claim. Confirm eligibility by filling out and signing the employer's statement and having the insured fill out and sign the form.

Declaration of Attending Physician - Original Request - 0202501A
2 pages - 88 kb
This form must be completed by the attending physician if it is the first medical consultation for a short or long term disability benefits claim. For subsequent disability evaluations, please use form no. 0202601A. Fees required to have the form filled out are at the insured's expense.

Declaration of Attending Physician - Additional Report - 0202601A
2 pages - 80 kb
This form must be completed by the attending physician for the purpose of evaluating the course of the disability. Fees required to have the form filled out are at the insured's expense.

Policyholder Guide - 03143E
20 pages - 293 kb
A Policyholders' guide to Disability Management.

Claim - Convalescent Care - 98130E01
2 pages - 152 kb E-Form
Form to submit a claim for home care services, provided these expenses are covered by your contract. The claim must include justifying documents and be completed by the physician who recommended the convalescence.

Notice of Return to Work - 00159E01
1 page - 40 kb
Note: If an insured was receiving disability benefits and returns to work, use this form to inform us on the day of his return to work.

Accidental Loss

Claim - Accidental Dismemberment or Loss of Sight / Fractures - 0280901A
2 pages - 50 kb
This form should be used in the event of the accidental loss of a limb or sight, for a fracture or a loss of use, if covered under the Benefit. Proof must be included with the claim.

Death of Member or Dependent

Death - Claim - 0222701A
2 pages - 36 kb
This form should be used in the event of the death of an insured or one of his dependents. Proof must be included with the claim.

Declaration of Status for the Deceased Common-Law Spouse - 01311E01
1 page - 333 kb E-Form
This form should be used in the event of the death of common-law spouse and must be appended to "Death Claim" form.

Other

Our On-line Services - For Plan Members - 03239E04
2 pages - 388 kb
Pamphlet describing how to register to the Plan Member secure site and access the health claims history.

Declaration of Dependent Children Aged 18 to 25 or 21 to 25 Inclusive
(According to Contract Provisions) - 1913101A
1 page - 53 kb E-Form
This form should be used when an insured wishes to obtain a drug payment card coverage for his dependent child aged 18, or aged 21 to 25 inclusively as stipulated in your contract if he is a full-time student. The form confirming the full-time status must be filled out for each school term.

Direct Deposit and Electronic Notice Enrollment - 07019E01
1 page - 49 kb E-Form
This form must be completed by plan members who wish to have their health and dental claim payments deposited directly into their bank account. This service informs them by e-mail when their claim has been processed.