Disability, critical illness, life, health benefit, travel and pension plan forms from Canadian insurers, including the disability statement most carriers now share.
Private insurers and pension plans ask the treating clinician to document disability, critical illness, death and health benefit claims. For disability, most carriers now use one form: the Initial Disability Insurance Medical Statement, the industry standard for short- and long-term disability that CLHIA announced on October 1, 2025. Sun Life, Manulife, Canada Life, Desjardins, Empire Life, Equitable Life, The Co-operators, Medavie and the Alberta, Saskatchewan and Manitoba Blue Cross plans use it.
The statement runs 4 pages, the form says the patient pays any fee, and insurers may take up to a year to retire their own forms. Beyond disability, this list covers critical illness and death claim statements, health plan pre-approvals for CPAP or nursing care, drug prior authorization and trip cancellation forms, and pension plan disability reports from OTPP, OMERS, LAPP and others. Vero Documents fills PDF forms like these from the visit note and chart; you review, sign, and download, print or email the form with the patient's consent.
Déclaration médicale initiale pour l’assurance invalidité
Standard industry medical statement used to start a short- or long-term disability claim with any participating Canadian life and health insurer.
Initial medical statement for a Saskatchewan health-care employee's application to the 3sHealth Disability Income Plan (CUPE, General, SEIU-West and SUN plans).
Alberta Blue Cross copy of the industry initial medical statement for disability claims.
Attending physician statement for a critical illness benefit claim (group or personal plan).
Special authorization request for weight-loss drugs under Alberta Blue Cross plans.
307 CANDisability claim under Scotiabank commercial (business) credit insurance, group policy 10650; the physician completes the attached Attending Physician's Statement.
Disability benefit claim for RBC creditor-insured Royal Credit Lines, personal loans and mortgages; the clinician completes the embedded Initial Disability Insurance Medical Statement.
Disability claim for CIBC creditor disability insurance; the clinician completes the embedded CLHIA Initial Disability Insurance Medical Statement.
Disability claim for TD Protection Plan creditor disability insurance on loans and mortgages; the clinician completes Part B.
Beneva (formerly SSQ Insurance and La Capitale) group claim forms, including any attending physician statements, are listed only after entering a group or policy number.
Individual critical illness, accident-sickness and disability claims start with an online request; no physician statement PDFs are published.
Search tool for Beneva group prior authorization (exception drug) forms by drug or medical condition.
Mental-health-specific attending physician questionnaire for a disability claim.
Attending physician statement for a short-term disability claim under Blue Cross (Canassurance) disability insurance.
Critical illness claim package with claimant's statement, attending physician's statement and medical certificate.
Supplementary attending physician report confirming an ongoing long-term disability.
BMO Insurance life and critical illness claims; BMO sends the claims package, including any physician statements, after the claim is started.
Medical statement for Canada Life workplace STD, LTD and early referral services claims and for group life premium waiver claims; Canada Life links the CLHIA harmonized form.
Physician's initial statement for an individual (advisor-sold) critical illness insurance claim.
Physician's initial statement for an individual critical illness claim for an insured child.
Attending physician certifies the death and cause of death for a workplace (group) life insurance claim.
Attending physician's certificate supporting an individual accidental dismemberment or specific-loss claim.
Requests an exception to diabetes step-therapy rules.
Prior authorization request for medical cannabis coverage under a workplace drug plan.
Family of drug-specific prior authorization forms for Canada Life workplace drug plans.
Drug claim assessment for Quebec members under the RAMQ exception patient program.
Drug claim assessment for Quebec members prescribed a drug on the RAMQ exceptional medications list.
Requests blood glucose test strips above the provincially indicated quantities within a 365-day period.
Requests coverage of an originator biologic instead of a biosimilar.
Requests coverage of a brand-name drug instead of the lower-cost alternative.
Requests approval of a dose increase for a drug already approved under prior authorization.
Physician assessment supporting coverage of a CPAP/APAP machine under a workplace health plan.
Pre-care assessment to set the amount of private nursing care covered under a workplace health plan.
Applies to continue workplace benefits coverage for an over-age dependant with a disability.
Pre-approval application sent before each gender affirmation procedure.
Physician's initial statement for a workplace (group) critical illness claim for an employee, spouse or child.
Treating physician's declaration supporting a trip cancellation, interruption or delayed-return claim for illness or injury.
Standard drug special authorization request for plans administered by ClaimSecure.
2002000-021A-CL-64Pre-approval assessment for a hospital bed purchase or rental.
2002000-022A-CL-64Pre-approval assessment for private nursing care.
2002000-028A-CL-64Pre-approval assessment for wheelchair purchase or rental.
2002000-029A-CLPre-approval questionnaire for a custom knee brace, completed before estimate approval.
Déclaration médicale initiale pour l’assurance invalidité
Initial medical statement (industry harmonized form) for a Desjardins individual disability insurance claim.
Family of drug-specific prior authorization forms for Desjardins group drug plans.
Déclaration initiale du médecin traitant
Initial attending physician's statement for a Desjardins group disability claim, with a physical-illness version on one side and a psychological-illness version on the reverse.
Follow-up attending physician report for an ongoing Desjardins group disability claim, with physical and psychological illness versions.
Soins infirmiers à domicile - Demande de renseignements supplémentaires
Clinical information supporting a claim for home nursing care.
Confirmation de la déficience fonctionnelle d’un enfant à charge
Confirms a dependent child's functional impairment so group coverage can continue.
Demande d'autorisation générale pour un médicament
General drug prior authorization request for drugs without their own form.
Demande de remboursement pour un médicament de marque
Requests reimbursement of a brand-name drug instead of the generic.
Déclaration du médecin traitant pour un décès
Physician's statement for a Desjardins group life (death) claim.
Déclaration du médecin traitant pour une maladie grave
Attending physician's statement for a Desjardins critical illness claim.
Déclaration du médecin traitant – Rapport supplémentaire
Follow-up attending physician report for an ongoing Desjardins individual disability claim.
Demande de remboursement pour un médicament biologique de référence
Requests reimbursement of a reference (originator) biologic instead of a biosimilar.
Industry initial medical statement used for Empire Life group short- and long-term disability claims.
Drug-specific prior authorization forms for Empire Life group plans, retrieved through Express Scripts Canada's form search.
Group life and accidental death claim form that includes an attending physician statement.
GRP-3918-ENPre-authorization for gender affirmation procedures under an Empire Life group plan.
GRP-5008-ENRequests approval of a drug substitution under the Extended Health Benefit provisions.
Physician's proof-of-death statement for a group life insurance claim.
Equitable's copy of the industry initial medical statement for group disability claims.
PBM form search for drug prior authorization forms for the plan sponsors and insurers that Express Scripts Canada manages.
Attending physician's statement for an initial long-term disability claim under the federal Public Service Management Insurance Plan (PSMIP).
Attending clinician's medical statement supporting an initial long-term disability claim under the federal Public Service Disability Insurance (DI) Plan, policy 12500-G.
Initial attending physician's statement for a Canadian Armed Forces member's SISIP long-term disability claim on release (Manulife group policy 901102).
Follow-up medical update requested on an existing SISIP LTD claim to assess continuing entitlement (Manulife group policies 901102/911104/911105).
Life claim package for deaths in policy years three to five; includes a physician's proof-of-death statement.
Physician statement for an initial long-term disability claim by BC health-care, community social services and public-sector employees covered by HBT plans.
Periodic physician update on an ongoing HBT long-term disability claim (LTD maintenance).
Maladies graves – Déclaration du médecin
Family of condition-specific physician statements for Humania critical illness claims.
Physician's statement for a Humania life insurance (death) claim.
Supplementary attending physician report for an ongoing disability claim due to a physical illness.
Supplementary attending physician report for an ongoing disability claim due to a psychological illness.
Physician's proof-of-death statement for iA Special Markets (association/affinity group) accidental death claims.
Demande d’autorisation d’un médicament d’exception
Exception drug authorization request under iA individual health insurance.
F54-361ARéclamation – Assurance vie
Group life insurance (death) claim; the physician's statement is required above certain coverage amounts.
Réclamation – Mutilation accidentelle
Group accidental dismemberment claim with an attending physician's statement.
F54-381AInvalidité – Demande initiale
Initial group disability claim package with member, employer and attending physician declarations for physical and/or psychological illness.
F54-382AInvalidité – Demande de prolongation
Ongoing (supplementary) group disability update with attending physician's statements on current situation, treatment, follow-up, prognosis, limitations and restrictions.
Formulaire d'exception pour un médicament d'origine
Requests coverage of a brand-name drug instead of the generic.
F54-856ARéclamation – Maladie grave
Group critical illness claim form with an attending physician's statement.
Formulaire d’autorisation préalable – Médicaments
General prior authorization request for group drug plans; iA's drug-specific variants are listed on the same page.
F54-898AQuestionnaire pour les soins infirmiers
Supports a group health claim for private nursing care.
Personne à charge ayant un handicap et dépassant l'âge maximal
Supports continued group coverage for an over-age dependent with a disability.
Formulaire d’exception pour un médicament biologique
Requests coverage of a reference biologic instead of a biosimilar.
Recommendation supporting a claim for assisted care or private nursing services.
Attending physician's statement for a critical condition benefit application.
Physician report supporting a Manitoba Blue Cross trip cancellation claim: diagnosis, first visit, hospital confinement, and whether the condition precluded travel.
Special authorization request for continuous or flash glucose monitoring coverage.
Manitoba Blue Cross copy of the industry initial medical statement for disability benefit claims.
Pre-authorization or claim for custom orthotics and orthopedic shoes or modifications.
Manulife's copy of the industry initial medical statement; the same form is used for short- and long-term disability claims.
Family of drug-specific prior authorization forms for Manulife group drug plans.
Requests coverage of a brand-name drug when the lowest-cost interchangeable drug cannot be tolerated or is ineffective.
Family of drug-specific prior authorization forms for Medavie group drug plans.
Attending physician's statement for a group critical condition (critical illness) benefit claim.
Medavie's copy of the industry initial medical statement for group disability claims.
FORM-969EClaim for a terminal illness (accelerated life) benefit, including an attending physician's statement.
Physician statement for long-term disability benefits or continuation of benefits during disability (waiver of premium) under Province of New Brunswick employee plans.
0199.022Prior authorization request for drugs that need approval under Pacific Blue Cross Blue Chip plans.
Asks Pacific Blue Cross ahead of time whether a sleep apnea device (e.g., CPAP) will be covered.
Physician statement for a disability pension application under the NB Teachers' Pension Plan or the Provincial Court Act / Provincial Court Judges' Pension Act.
Doctor's medical report supporting an OMERS disability contribution waiver and/or disability pension.
Medical report for medical pre-approval of, or application for, an OTPP full or partial disability pension; reviewed by OTPP's independent medical referee.
Physician statement accompanying a LAPP partial or total disability pension application.
Physician report for a member applying for, or being reassessed for, a disability benefit under Ontario's Public Service Pension Plan.
Physician report establishing that a dependant of a deceased PSPP member has a continuing mental or physical disability, for a survivor pension.
Physician statement accompanying an Alberta Public Service Pension Plan partial or total disability pension application.
Physician statement for an RBC individual disability insurance claim; RBC directs physicians to the CLHIA form.
Family of condition-specific physician statements for RBC individual critical illness claims (e.g., Cancer, Cardiovascular).
Rapport médical pour une prestation de maladie en phase terminale d'un régime de retraite du secteur public
Medical report supporting a terminal-illness benefit claim under a Québec public-sector pension plan.
Rapport médical pour une prestation d'invalidité d'un régime de retraite du secteur public
Medical report supporting a disability-benefit claim under a Québec public-sector pension plan (RREGOP, PPMP, etc.) administered by Retraite Québec.
Industry initial medical statement used for Saskatchewan Blue Cross disability claims.
Special authorization request for prescription drugs under Saskatchewan Blue Cross plans.
DISB-1006Physician's proof-of-death statement for life and AD&D claims.
Attending physician's statement for a critical illness claim.
5548-SL-IDIMS-EDéclaration médicale initiale pour l’assurance invalidité
Sun Life's copy of the industry initial medical statement for new short-term disability, long-term disability and salary continuance claims, replacing Sun Life's Attending Physician's Statement for new claims.
Family of drug-specific prior authorization forms for Sun Life group drug plans.
Choix du mode de règlement et déclaration de sinistre : Déclaration du médecin
Physician's statement for a Sun Life group life (death) claim.
490SC-AS-HH-P-EServices d’aménagement des conditions de travail – Déclaration du médecin traitant
Medical information supporting a Sun Life Accommodation Services referral (workplace accommodation / stay-at-work support).
Demande de règlement – Exonération de primes – Déclaration du médecin sur l'invalidité
Physician's statement supporting a group life insurance waiver-of-premium claim for a disabled plan member.
Family of condition-specific physician statements for group critical illness claims, including dependent children's covered illnesses.
Physician statement for a group accidental dismemberment claim.
Industry initial medical statement for Co-operators group disability claims.
Physician's proof-of-death statement for a group life claim.
General physician statement for a group critical disease claim.
Attending physician statement supporting a group life waiver-of-premium claim.
Attending physician statement for Co-operators' group Attendance Support Program (early absence management).
Mental-health attending physician's statement for Co-operators' group early intervention program.
Mental-health-specific attending physician's statement for a group LTD claim.
Mental-health-specific attending physician's statement for a group STD claim.
GL2647Functional abilities assessment supporting a disability claim and return-to-work planning.
Initial disability medical statement for Wawanesa Life group LTD, STD and waiver-of-premium claims.
Family of 33 condition-specific physician statements for Wawanesa Life group critical illness claims.
Supplementary (ongoing) clinical information for a Wawanesa Life group disability claim.
Individual life and critical illness claims use a claims package requested from Wawanesa Life's claims team.
Physician's proof-of-death statement for a Wawanesa Life group life claim.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Sun Life, Manulife, Canada Life, Desjardins (individual disability), Empire Life, Equitable Life, The Co-operators, Medavie Blue Cross, and Alberta, Saskatchewan and Manitoba Blue Cross publish their own copies, such as Manulife's GBF0002E, Sun Life's 5548-SL-IDIMS-E and Medavie's FORM-401E, or link to the CLHIA form. RBC directs physicians to it, and creditor disability claims on CIBC, RBC and TD loans embed it. The federal public service disability plans use it too. Some older insurer statements remain in use during the changeover.
Yes, in two cases. If the patient has returned to work, or the disability will last under 4 weeks, the clinician may stop after page 2 and sign. Otherwise complete Section 2, the Medical Statement, in full; the patient completes Section 1, Patient Information and Consent. The form is a 4-page fillable PDF that goes back to the patient to submit to their insurer, since CLHIA does not process claims.
Usually the patient. The CLHIA statement and most insurer copies print that the patient is responsible for any fees, and Desjardins, SISIP and the bank creditor claim forms say the same. There are exceptions: The Co-operators reimburses the member for its Functional Abilities form (GL2647) up to a limit stated on the form, and 3sHealth pays a standard fee for forms it requests once an LTD claim is approved.
Yes. Ontario Teachers' Pension Plan uses a medical report for disability pensions (form 0202), OMERS uses form 147, Ontario Pension Board uses OPB 3003 for the Public Service Pension Plan, and Alberta's LAPP uses the Confidential Medical Statement (LA163). Vestcor has an attending physician's statement for New Brunswick teachers, and Retraite Québec's RSP-502 covers public-sector plans, separate from QPP disability. Most say the patient pays any fee.