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Desjardins 09296E: Child's Functional Impairment Form

Desjardins Insurance uses this form to confirm a dependent child's functional impairment so the child's group insurance coverage can continue. The plan member describes the impairment, work experience and any government assistance, and the child's attending physician documents the diagnosis, whether it is permanent, its effect on everyday activities and work, and the prognosis.

Who completes it

The child's attending physician completes Section D (medical information) and Section E (identification, with licence number and signature). The plan member completes Sections A to C, including the declaration and authorization.

Submitting and payment

How to submit it
The form and any required documents can be uploaded through the plan member's Desjardins group insurance account using Send documents, or mailed to Desjardins Insurance, keeping a copy.

Good to know

  • Indicate whether the clinical diagnosis is permanent or temporary, and describe the nature and degree of the mental or physical functional impairment.
  • Section D lists up to four periods when the child was unable to work or attend school full-time because of the impairment.
  • If an application for government assistance related to the impairment was made, the plan member reports the decision and attaches copies of all documents exchanged with the government.
  • The French version is numbered 09296F, and Desjardins lists the English form with its administrative claim forms.

Get the official form

Download the current version from the source each time; forms change without notice.

Confirmation of a dependent child's functional impairment

Confirmation de la déficience fonctionnelle d’un enfant à charge

Official pagePDFVersion française

Fill it with Vero

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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How this list is checked

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.

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Frequently asked questions

Is Desjardins form 09296E available in French?

Yes. The French version, Confirmation de la déficience fonctionnelle d'un enfant à charge, is numbered 09296F. The English version, 09296E, is dated 2025-12, and Desjardins lists it with its administrative claim forms for group insurance.

What does the physician complete on the Desjardins child functional impairment form?

Section D asks for the clinical diagnosis and whether it is permanent or temporary, the nature and degree of the impairment, the date of diagnosis, how far it prevents normal everyday activities, what work the child can do, periods unable to work or attend school full-time, and your prognosis. Section E identifies you.

How is form 09296E sent to Desjardins?

The plan member can upload it through their Desjardins group insurance account, using Send documents and choosing Health insurance, then Forms, then this form's name. It can also be mailed to Desjardins Insurance, and Desjardins asks that a copy be kept for your records.