FNISLP Group Insurance Short & Long Term Disability
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.
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.
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 .
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.
Education and Work History
Employee must complete this form, sign and return it to First Nations Insurance Services Limited Partnership’s office for processing.
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.
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’s office for processing.
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.
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.
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
Process to Submit Formal Notice of Case Review
When requested, and where an employee wishes to appeal the insurer’s decision to decline benefits, the Employee must complete this form, sign and return it to First Nations Insurance Services Limited Partnership’s office for processing.
Return to Work Notice
Employer must complete this form, sign and return to First Nations Insurance Services
Limited Partnership’s office for processing.