Fillable CONFIRMATION OF A DEPENDENT CHILDS FUNCTIONAL IMPAIRMENT (Desjardins Insurace)

Fill Online, Printable, Fillable, Blank CONFIRMATION OF A DEPENDENT CHILDS FUNCTIONAL IMPAIRMENT (Desjardins Insurace) Form

Use Fill to complete blank online DESJARDINS INSURACE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CONFIRMATION OF A DEPENDENT CHILDS FUNCTIONAL IMPAIRMENT (Desjardins Insurace)

On average this form takes 6 minutes to complete

The CONFIRMATION OF A DEPENDENT CHILDS FUNCTIONAL IMPAIRMENT (Desjardins Insurace) form is 1 page long and contains:

  • 0 signatures
  • 6 check-boxes
  • 22 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Desjardins Insurace forms online.

BROWSE DESJARDINS INSURACE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
09296E (2020-02)
PLEASE HAVE THE CHILD’S ATTENDING PHYSICIAN COMPLETE THE BACK OF THIS FORM.
Desjardins Insurance life health rerement logo
Member’s last name and rst name
Policy or group or contract number Cercate number
Dependent child’s last name and rst name Sex Date of birth of dependent child
Number, street, apartment City Province Postal code
M F
YYYY MM DD
Yes No
Name of the person the child lives with
YYYY MM DD
1. Please describe the child’s funconal impairment:
2. Start date of funconal impairment:
3. Please describe the child’s work experience:
Please describe the limitaons that prevent the child from being gainfully employed:
Yes No
All the informaon I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Informaon Management secon
at the back of this form. I authorize Desjardins Financial Security Life Assurance Company, hereinaer Desjardins Insurance, strictly for the purposes of
managing my le and seling this claim to: (a) collect from any person or legal enty, or from any public or parapublic organizaon, only the informaon
deemed necessary to manage my le. The non-exhausve list of sources from which informaon may be collected includes health care professionals or
facilies, insurance companies; (b) communicate to the said persons or organizaons only the personal informaon about me that is deemed necessary for
the purposes of my le; (c) when necessary use the personal informaon it may have about me in exisng les that are now closed. This authorizaon is
also valid for the collecon, use and communicaon of personal informaon concerning my dependents, insofar as applicable to the claim.
A photocopy of this authorizaon is as valid as the original.
Signature of the member: Date:
If an applicaon related to a funconal impairment has been made, please indicate the decision (approval or denial) and provide us with a copy of all
documents submied to and received from the government:
4. Is the child eligible for government assistance because of his/her funconal impairment?
If no, where does
the child live?
Does the child live with you?
Group Insurance - Health Claims
CONFIRMATION OF A DEPENDENT
CHILD’S FUNCTIONAL IMPAIRMENT
A IDENTIFICATION
B GENERAL INFORMATION –
To be completed by the member.
C DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
ADDRESS C. P. 3950 LÉVIS QUÉBEC G 6 V 9 X 8 WEB SITE DESJARDINS LIFE INSURANCE DOT COM SLASH PLAN MEMBER TELEPHONE 1 8 0 0 2 6 3 1 8 1 0
PRINT
RESET
Last name and rst name of the physician License number
Number, street, suite City Province Postal code
Telephone number Fax number Email address
I hereby cerfy that the above answers are full and true.
Signature of the physician: Date:
Desjardins Insurance handles the personal informaon it has on you in a condenal manner. Desjardins Insurance keeps this informaon on le so that you
may benet from group insurance services oered by the Company. This informaon is consulted solely by Desjardins Insurance employees who need to
do so in the course of their work. Desjardins Insurance may compile anonymized personal informaon for stascal and informaonal purposes. Desjardins
Insurance may also communicate with plan members to provide them with opmal health management. You have the right to consult your le. You may
also have informaon corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a wrien request to
the following address: Privacy Ocer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client
list to oer its clients an insurance product following the terminaon of their group insurance. If you do not wish to receive these oers, you may have your
name removed from the list. To do so, you must send a wrien request to the Privacy Ocer at Desjardins Insurance.
1. Clinical diagnosis: Permanent Temporary
2. Please describe the nature and degree of the mental or physical funconal impairment:
3. Date of diagnosis:
4. To what degree does the physical or mental funconal impairment prevent the child from performing his/her normal everyday acvies?
5. What type of work is the child capable of doing?
7. What is your prognosis with regard to the child’s funconal impairment?
YYYY MM DD
YYYY MM DD YYYY MM DD YYYY MM DD YYYY MM DD
YYYY MM DD
YYYY MM DD YYYY MM DD YYYY MM DD
D MEDICAL INFORMATION –
To be completed by the aending physician.
E IDENTIFICATION OF THE PHYSICIAN –
To be completed by the aending physician.
F PERSONAL INFORMATION MANAGEMENT
6. Indicate the periods during which the child was not able to work or aend school full me because of his/her funconal impairment:
First period: From To Second period: From To
Third period: From To Fourth period: From To
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CONFIRMATION OF A DEPENDENT CHILDS FUNCTIONAL IMPAIRMENT (Desjardins Insurace)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 February 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document