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Forms & Downloads - FNIS Group Insurance Association Plan
FNISLP Group Insurance Short & Long Term Disability

The following seven forms must be completed, signed and forwarded to First Nations Insurance Services Limited Partnership's office for processing in order to make a claim for Short or Long Term Disability Benefits.

Blue Cross: Electronic Funds Transfer (EFT) Authorization Group Member
Employee must forward the completed and signed Authorization form and VOIDED
cheque along with their claim to First Nations Insurance Services Limited Partnership's office
in order to take advantage of this option. When a claim is processed, their benefit payment will
be deposited to the account provided through Electronic Funds Transfer. They need only
forward the Authorization and Voided cheque the one time, unless there is a change to
their banking information. If the employee cannot provide a "Void" cheque, they must
have their bank complete and stamp this form. Download Form

Application For Benefits Employer's Statement
Employer must complete this form, sign and return it to the First Nations Insurance
Services Limited Partnership's office for processing. Download Form

Job Description
Employer must complete this form, sign, have employee sign then return it to First Nations
Insurance Services Limited Partnership's office for processing . Download Form

Application for Benefits Employee's Statement / Authorization
Employee mufdsafst complete this form, sign and return it to First Nations Insurance Services
Limited Partnership's office for processing.Download Form

Education and Work History
Employee must complete this form, sign and return it to First Nations Insurance Services
Limited Partnership's office for processing. Download Form

Attending Physician's Statement
Employee must have their Licensed Physician or Specialist complete the applicable form,
sign and return it to first Nation's Insurance Services Limited Partnership's office for processing.

• Attending Physician's Statement Cardiac. Download Form
• Attending Physician's Statement General. Download Form
• Attending Physician's Statement Musculoskeletal. Download Form
• Attending Physician's Statement Psychiatric. Download Form
• Attending Physician's Statement Rheumatology. Download Form
• Motor Vehicle Accident Questionnaire. Download Form

The following forms may be required in addition to the forms listed above when requested by FNISLP and/ or the Insurer for claiming Long Term Disability benefits.

Claimant's Statement of Continuing Disability
Only when requested, Employee must complete this form, sign and return to the First Nations
Insurance Services Limited Partnership's office for processing.Download Form

If your employee makes Canada Pension Plan contributions, these additional forms are required
by Blue Cross for existing Short Term Disability and new Long Term Disability claimant's once
approved for Long Term Disability:

Irrevocable Consent to Deduct and Pay an Insurer
Employee must complete this form, sign and return it to First Nations Insurance
Services Limited Partnership'soffice for processing. Download Form

Consent for Service Canada and Insurer to Communicate Disability Benefit Information
Employee must complete this form, sign and return it to First Nations Insurance
Services Limited Partnership's office for processing. Download Form

Authorization to Communicate Information Canada Pension Plan
Employee must complete this form, sign and return it to First Nations Insurance Services
Limited Partnership's office for processing. Download Form

Additional forms are required by the Canada Pension Plan Disability program to apply for the CPP Disability benefits, as follows:

• Application for Disability Benefits CPP
• Authorization to Communicate Information CPP
• Child Rearing Provision CPP
• Consent for Service Canada to Obtain Personal In-formation Medical Report
• Consent for Service Canada to Obtain Personal Information Service Canada
• Medical Report
• Questionnaire for Disability Benefits CCP

Here are some guides to assist you in completing the forms above:
• General Information Guide
• Information Sheet for the Child Rearing Provision

The following form is required only when requested by FNISLP and/ or Insurer:

Process to Submit Formal Notice of Case Review
When requested, and where an employee wishes to appeal the insurer'sdecision to decline
benefits, the Employee must complete this form, sign and return it to First Nations Insurance
Services Limited Partnership's office for processing. Download Form

Return to Work Notice
Employer must complete this form, sign and return to First Nations Insurance Services
Limited Partnership's office for processing. Download Not Available Yet

 

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