08317E (2018-03)
Desjardins Insurance refers to Desjardins Financial Security Life Assurance Company.
PLEASE COMPLETE THE BACK OF THE FORM.
Current salary Amount Salary effective date Job status
Indicate days in normal work week Hours worked Type of schedule Premium paid by
per week
Date of employment
Occupation Date last worked No. of hours worked
Ye s
No
If "Yes", date of accident:
Ye s
No If "Yes", indicate below:
Type: Amount: Period:
Yes
No
Yes
No If "Yes", indicate below:
CNESST / WCB / WSIB / WHSCC
CPP / QPP
SAAQ (Québec only)
Other, specify:
Date Filed: Decision Rendered: Amount:
Yes
No If "Yes", on what date?
Ye s
No - Termination date:
Reason:
Ye s
No
No
Yes - Please specify:
Ye s
No
%
YYYY MM DD
Weekly
Monthly
Every two weeks
$
Variable
Rotating
Full time
Part time
SUN
MON
TUE
WED
THU
FRI
SAT
Employer
Employee
Both
YYYY MM DD
YYYY MM DD
$
$
1
2
3
4
5 6
7
8 9
10
YYYY MM DD
11
12
14
15
YYYY MM DD
YYYY MM DD
16
17
13
18
YYYY MM DD
A - IDENTIFICATION
We are unable to assess this claim unless all questions are answered completely.
EMPLOYEE Last name and first name Certificate or identification no. Social insurance no.
*
Address of employee - No., street, apt. City Province Postal code
Telephone no.: ( ) - E-mail address:
COMPLETE IF SELF-ADMINISTERED: Effective date of coverage: Class no.:
YYYY MM DD
*
Social insurance number is necessary only if the disability claims are taxable.
POLICYHOLDER OR EMPLOYER Name Policy or group or contract no. Division no.
Address of policyholder or employer - No., street, suite City Province Postal code
Telephone no.: ( ) - Fax no.: ( ) -
If so, please indicate the percentage of employment income that is not taxable:
Is your employee eligible for an exemption under the Indian Act (R.S.C. (1985), c. I-5)?
Are there any work-related factors that may have contributed to the employee’s disability or had an impact on their return-to-work?
Was this person given a record of employment?
Is this person still in your employ?
Has the employee returned to work?
Has a claim been filed with a government agency?
If the employee is pregnant, has an application for a preventive withdrawal been, or will it be, submitted to the CNESST (Québec only)?
Did or will the employee receive any income during the disability period?
(Type: holiday pay, maternity, disability, EI benefits, salary, lump sum, other)
Is disability due to an accident?
If the benefits are taxable, the basic tax deductions will be made.
In all other cases, please provide the appropriate tax forms.
B - GENERAL INFORMATION
GROUP INSURANCE - DISABILITY CLAIMS
DISABILITY OR WAIVER OF PREMIUM CLAIM
EMPLOYER STATEMENT
Submit online:
desjardinslifeinsurance.com/send
Complete and save the form on your computer first.
Keep original forms for your records.
By mail:
C. P. 3875 succ. Lévis
Lévis (Québec) G6V 0A7
Send original forms and keep copies
for your records.
By fax:
1-844-409-6575 (toll free)
418-835-0194
Keep original forms for your records.
Submit online.
Complete and save the form on your computer first. Keep original forms for your records.
Submit by mail: C P 3 8 7 5 succursale Lévis, Lévis, Québec, G 6
V 0 A 7. Send original forms and keep copies for your records.
Submit by fax: toll free 1 8 4 4 4 0 9 6 5 7 5 or 4 1 8 8 3 5 0 1 9 4.
Keep original forms for your records.
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