Desjardins Insurance uses its copy of the industry Initial Disability Insurance Medical Statement (020255A, June 2025 version) for claims under individual disability insurance policies. The insured completes Desjardins' disabled person's initial statement, and the doctor completes this medical statement. Benefits are paid only after the waiting period set in the policy.
The insured completes Section 1 (patient information, medications and consent). The family physician, consulting specialist or other medical provider completes Section 2, the Medical Statement, to the best of their knowledge.
Download the current version from the source each time; forms change without notice.
Initial Disability Insurance Medical Statement
Déclaration médicale initiale pour l’assurance invalidité
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.
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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Yes. The French version is the Déclaration médicale initiale pour l'assurance invalidité, posted on Desjardins' French claims page. The English version prints 020255A and Version: June 2025 in its footer, matching the industry standard form used by many Canadian insurers.
Not always. If the patient has returned to work or the disability will last less than 4 weeks, the form says to stop after the hospitalization and surgery questions and sign. Otherwise, complete all pages, including investigations, clinical findings, restrictions, prognosis and return-to-work goals.
The insured calls Desjardins to learn which documents are needed, completes the claim form, has the doctor complete the physician's statement, and submits everything. Desjardins reviews the claim once it has the documents, contacts the insured about approval, and pays benefits after the waiting period.