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Plan Administrators

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Forms at your fingertips

Save time by accessing our most frequently used forms, in a fillable format.

Select the form you need and complete all necessary fields on-screen. Once complete, simply print the filled form and send it to the appropriate claims and administration office.

To order hard copies of any of these forms, please complete and return the Order form PC GB1306.

Adobe Acrobat Reader version 5.0 or higher is required to view and print these forms.

Administrative forms
G1053 Evidence of insurability
G1223 Request for conversion of group life insurance
G1285 Notice of change
G2229 Confirmation of school attendance
GE8000 Application form
GE8001 Request for change (I)
GE8002 Optional benefits
GE8003 Request for change (II)
GE8033 Address confirmation
GE9874 Beneficiary designation
PC GE10158 Participant authorization
PC GE10352 Application for total and permanent disability status for a dependent child
PC GE8289 Direct deposit
PC GE8004 Refusal to join
PC GB1306 Order form

Claim forms
Health care
GE10468 Medical and paramedical claim form
GE9205 Drug card claim reimbursement form (Assure health)
PC GE9183 Approval form – exception drugs
Dental care
GE8228 Dental claim form
G2019 Dental claim – accidental injury
Disability
GE10342 Disability claim form
G2277 Attending physician's supplementary statement
Life
G2007 Death claim
GB959 Living Benefit claim



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