FNISLP Group Insurance Death Claims

BASIC, DEPENDENT LIFE & OPTIONAL LIFE INSURANCE

The following three forms must be completed and forwarded to First Nations Insurance Services Limited Partnership’s office for processing in order to claim life benefits for either an employee or an eligible dependent’s death.

Death Claim Form

One of these forms must be completed by each beneficiary (or on behalf of each  beneficiary where a minor is involved) in the event of the death of an employee and return form(s) to First Nations Insurance Services Limited Partnership’s office for processing.

  • Statement of Employer
    Employer must complete section
  • Employee Information
    Employer must complete this section in the event of an employee’s or his/her
    eligible dependent’s death.
  • Statement of Claimant
    Each claimant/ beneficiary (designated by deceased employee) must complete this section
  • Complete If Death Was Result of Accident
    Each claimant/ beneficiary (designated by deceased employee) must complete this
    section where death of Employee/ Eligible Dependent was a result of an accident.
  • Certification
    Each claimant/beneficiary (designated by deceased employee) must complete and have their
    signature witnessed in this section
  • + Blue Cross
    Each claimant/ beneficiary (designated by deceased employee) must complete and have
    their signature witnessed in this section.
Proof of Death Physician's Statement

The Claimant/ beneficiary (designated by deceased employee) must have this form completed by Attending Physician. Any charge associated with the completion of this form is the claimant’s responsibility.

BASIC ACCIDENTAL DEATH AND DISMEMBERMENT &
VOLUNTARY ACCIDENTAL DEATH AND DISMEMBERMENT

Employer/ Employee must notify First Nations Insurance Services Limited Partnership, in writing, within 30 days of Accidental Death or Dismemberment.

Group Life/Accidental Death Claim Form—Employer’s Statement, Group Life/Accidental Death Notice of Claim and Group Life/Accidental Death Claim Form Physician’s Statement
  • The Group Life/Accidental Death Claim Form—Employer’s Statement must be completed by the Employer
  • The Group Life/Accidental Death Notice of Claim form must be completed by each beneficiary designated by deceased employee.
  • The Claimant must have the Group Life/Accidental Death Claim Form Physician’s Statement completed by the Attending Physician.