<img height="1" width="1" style="display:none" src="https://www.facebook.com/tr?id=189745744856551&amp;ev=PageView&amp;noscript=1">

Application Forms

APPLICATION FORMS

For assistance please call
1-866-768-1477

What forms need to be completed?

All of the forms required to enroll in the Health Care Providers group benefits program are available from the table below. It is not necessary for every enrollee to complete all of the forms. Please refer to each form’s description to determine if your enrollment 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 or need information on alternative payment methods, please contact us: 1-866-768-1477

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

FORM 1

HCP Group Enrollment Form

ALL enrollees must complete this form.

FORM 2

Statement of Health Form

Any enrollee wishing to be considered for our Optimum health plan must submit Form 2 with their enrollment.

FORM 3

Employees Group Health Form

Signature or Supreme Enrollees ONLY

Any enrollee 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 open window
  • You have chosen to apply for any optional or additional life insurance or long term disability

FORM 4

Worksheet /Request for Optional Life and Long Term Disability 

Signature or Supreme Enrollees ONLY

Any enrollee who chooses to apply for optional life insurance and/or excess long term disability c must complete this worksheet.

FORM 5

Request for Optional Group Life for a Spouse

Signature or Supreme Enrollees ONLY

Any enrollee who chooses to apply for spousal life insurance.

FORM 6

Request for Optional Group Life for a Child

Signature or Supreme Enrollees ONLY

Any enrollee who chooses to apply for child life insurance.

FORM 7

New Primary Application Form

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

FORM C1:

Health Care Providers Change Form - Personal Information

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

FORM C2:

Health Care Providers Change Form - Policy/Coverage

Any current plan member looking to make changes to his/her package or plan coverage options

FORM B1:

Health Care Providers Change Form - Beneficiary Request

Signature or Supreme plan members only. 

 

Any plan current plan member looking to make changes to his/her beneficiary 

our partners & associates

HMA_new_logo.jpg
partner7-1.jpg
The-Co-operators-logo
get-maple