Insurance Forms

Insurance Plan

  • Insurance Plan
    Equity's Accident and Sickness Insurance Plan, underwritten by Chubb Life Insurance Company of Canada.

Medical / Paramedical Claim Forms

  • Accidental Dental
    Use this form to claim reimbursement for dental expenses incurred when treatment is required as a result of an accident. If the accident occurs while on contract, the reimbursement is no more than 80% per cent to a maximum of $2,500. If you are eligible for off-contract coverage, the reimbursement rate is 50% per cent. Note that this form must accompany a standard dental claim form completed by your dentist.
  • Health and Wellness
    This form is applicable to a variety of miscellaneous services and expenses as described on Page 2 of the form. There is an annual allowance of $100 for all members, whether you are on or off contract.
  • Claimant Statement
    Use this claim form for expenses related to physical therapies, medical expenses and alternative medicine. Note that maximums for physical therapies are different for all members: either $600 or $1,200 per treatment depending on your contract. Also, medical expenses have a collective maximum of $5,000 and alternative medicines have a collective maximum of $750. Supporting documentation may be required.
  • Practitioner Statement
    This form may be required depending on your claim situation and should accompany your Medical/Paramedical Claim Form.
  • Reasonable and Customary Fee Guide
    Reasonable and Customary Charges for Paramedical Services.

Income Replacement Benefit Claim Forms

  • Attending Physician Statement
    This form needs to accompany your Income Replacement Benefits Claim Form. It must be completed by your physician.
  • Claimant Statement
    Use this form to apply for income replacement if you need to drop out of a current or upcoming contract due to illness or injury. If you are working, you are insured for 60% per cent of your contractual weekly fee to a maximum of $1,500 per week for up to 52 weeks. Additional supporting documentation is required.