Plan members use this application to continue workplace benefits coverage for an over-age dependant with a disability. Canada Life assesses the dependant's education, employment history and need for help with daily tasks together with the attending physician's statement on physical and cognitive impairments, and asks that the form be completed in full to avoid delays in assessment.
The attending physician completes Section 5 and signs its declaration. The plan member completes Sections 1, 2 and 4, including the dependant's education, employment history, support needs and the privacy consent.
Download the current version from the source each time; forms change without notice.
Application for Dependant with a Disability Coverage
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Section 5, the attending physician's statement. It covers primary and secondary diagnoses with dates, physical and cognitive functional abilities, specific impairments, the type of work the patient can perform, current treatment and other care providers, prognosis and any other comments, followed by your declaration and signature.
No. The instructions state that physician's fees for providing medical information are not covered under the plan. The form also asks the plan member to complete it in full to avoid delays in assessment, and to keep a copy for their records.
Canada Life asks the plan member to attach any available supporting documents, such as recent educational assessments, recent cognitive assessments or neuropsychological reports, clinical notes or specialist reports issued in the past year, and an approval letter from a provincial disability program.