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Application Forms

APPLICATION FORMS

For assistance please call
1-866-768-1477

What forms need to be completed?

All of the forms required to make an application to the Health Care Providers group benefits program are available from the table below. It is not necessary for every applicant to complete all of the forms. Please refer to each form’s description to determine if your application requires that form.

You can fill in the forms online however we do require original signatures therefore each form must then be printed, signed and dated, and sent in to us by mail. (Click here for mailing addresses)

Already a plan member but looking to make changes to your coverage?

No problem. You’ll find the C1 Change Form in the table below. Complete this form online and send it in to us and we’ll be happy to make your changes.

Making Extended Health Care Benefit Claims

All claims are processed by Green Shield Canada and should be sent directly to their offices.Claim forms can be found here: Claim forms for do-it-yourself claim submission

All claim and claim form inquiries should be directed to Green Shield Canada directly by calling 1-888-711-1119.

How do I make payment?

Please remember to send TWO cheques in with your application. For a brief explanation of the TWO cheques click here.

If you have any questions at all please contact us: 1-866-768-1477

Any applicant required to show evidence that they are applying within 60 days of hire, retirement, full-time transfer etc. must complete this form

FORM 1

HCP Group Enrollment Form

ALL applicants must complete this form.

FORM 2

Statement of Health Form

Any applicant wishing to be considered for a LEVEL of Health Care coverage which would be an increase to the coverage he or she may be guaranteed to receive, must complete this form.

FORM 3

Employees Group Health Form

PLAN 1 APPLICANTS ONLY

Any applicant to whom ONE OR MORE of the following applies

  • You do not work at an endorsing hospital
  • You are not applying in a 60 Day Window
  • You have chosen to apply for any Optional or Additional Life insurance or Long Term Disability Coverage
FORM 4

Worksheet /Request for Optional Life and Long Term Disability Coverage

PLAN 1 APPLICANTS ONLY

Any applicant who chooses to apply for Optional Life insurance and/or Excess Long Term Disability coverage must complete this worksheet.

FORM 5

Request for Optional Group Life for a Spouse

PLAN 1 APPLICANTS ONLY

Any applicant who chooses to apply for Spousal Life insurance.

FORM 6

Request for Optional Group Life for a Child

PLAN 1 APPLICANTS ONLY

Any applicant who chooses to apply for Child Life insurance.

FORM 7

New Primary Application Form

Any applicant formerly covered under the HCP plan as a dependent and wishing to continue with coverage of his/her own

FORM 8

Request for Coverage for Overage Dependent

Any overage dependent attending a post-secondary educational institution and wishing to retain his/her coverage

FORM C1:

Health Care Providers Change Form

Any plan current plan member looking to make changes to his/her contact information or benefit coverage options

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