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Benefit
Claim Forms
Accidental Death & Dismemberment
(AD&D)
Mandatory for all eligible CISVA
employees, Accidental Death and
Dismemberment (AD&D) coverage provides
benefits should you be a victim of an
accident that costs your life, limb,
sight or hearing.
In the occasion of an AD&D claim, please
contact the Benefit Administration
Office for the applicable form.
Critical Illness
Claimants Statement
Mandatory for all eligible
CISVA employees, Critical
illness insurance alleviates
some of the stress due to
financial burden when an
insured is diagnosed with a
covered condition.
In the occasion of a
Critical Illness claim,
please forward this
completed document directly
to the Benefit
Administration Office.
There are additional
documents (including an
Employer claim form)
that need to accompany this
attachment. Therefore, do
not forward this claim
directly to the Claims
Department as indicated on
the claim form.
Dental
Dental
Direct Deposit form
Instructions on how to complete the Dental claim form
The Dental Care plan provides coverage
for a wide range of dental services,
from your regular check-ups to major
procedures such as root canals and
crowns. Even if you, your spouse or
dependent children are already enrolled
under your spouse’s plan, you may also
enroll in the CISVA plan, provided the
other plan allows double coverage.
Please refer to the
Enrollment forms section should
you wish to add/remove dependents from
your current coverage (complete a Group
Coverage Change form).
Disability
Short Term Disability Employee
Statement
Long Term Disability Employee
Statement
Short Term Disability Employer
Statement
Long Term Disability Employer
Statement
These benefits are available
to eligible employees and provide salary
replacement (wage-loss) benefits for
specified periods of time, to employees
who are disabled due to injury or
sickness.
Once the applicable documents have been
completed in full, please return them to
the Benefits Administration Office.
Extended Health Care
Extended
Health
Direct Deposit form
Instructions on how to complete the Extended Health
claim form
Out-of-Country
claim
Instructions on how to complete the Out-of-Country
claim form
Extended Health Care covers you for some
charges arising from
physician-recommended and medically
necessary services and supplies, beyond
the scope of MSP. Even if you or your
dependents are already enrolled under
your spouse’s plan, you may also enroll
in the CISVA plan, provided the other
plan allows double coverage.
Please refer to the
Enrollment forms section should
you wish to add/remove dependents from
your current coverage (complete a Group
Coverage Change form).
Submit all out-of-province/country
claims to Great-West Life using the
Out-of-Country claim form. Great-West
Life will coordinate payment of your
claim with MSP.
Fair
Pharmacare
Registration form
Fair Pharmacare indexes your provincial
deductible for prescriptions to your
income. Registering ensures that the
Fair Pharmacare plan, and not the CISVA
Benefits plan, pays for drug costs after
your new deductible has been reached,
making each benefits dollar go farther.
Send this form directly to Fair
PharmaCare for processing.
All B.C. residents who have a CareCard
from MSP should be registered for Fair
PharmaCare. Please note that effective
January 1, 2008 PharmaCare will no
longer reimburse prescription or medical
supply costs that were incurred before
the date a family registers for Fair
PharmaCare. To register or obtain
further information regarding Fair
PharmaCare, please visit their website
at
www.health.gov.bc.ca/pharme/.
Life
& Optional Life Insurance
Life Claim Brochure
Life Claim form
Mandatory for all eligible CISVA
employees, Basic Group Life provides
benefits to your designated beneficiary
in the event of your death, for whatever
cause. Spouses and dependent children
are not covered under this plan.
In the occasion of a Life claim (including
an Optional Life claim), please forward
this completed document directly to the
Benefit Administration Office.
There are additional documents that need
to accompany this attachment. Therefore,
do not forward this claim
directly to the Group Life Benefits
Department as indicated on the claim
form.
Pension – notice of death claim form
Notice of
death claimant’s form
In the occasion that a member of the
CISVA Registered Pension Plan dies, the
attached document must be completed by
the beneficiary and sent directly to the
Benefit Administration Office.
There are additional documents that need
to accompany this attachment. Therefore,
do not forward this claim
directly to Great-West life, Group
Retirement Services as indicated at
the top of the claim form.
Once this step has been completed,
Great-West life, Group Retirement
Services will contact the
beneficiary to provide a summary of
available options.
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