Claims Forms

Below is a listing of Great West Life forms to be used when making a claim for expenses or request for coverage.

Group Coverage Change Form
This forms needs to be completed when any major changes to the plan are made. For example, the addition of a dependant, change of name, marital status, waiving of health and dental benefits because you now have coverage through spouse's work.
Download (129KB)
Health Care Claim Form
This form is to be completed when seeking reimbursement of paramedical claims and/or drug claims or used to request an estimate of coverage for a specific procedure or equipment.
Download (100KB)
Assure Card Claim Form
This form is to be used to seek reimbursement for expenses via mail for drug claims (those that are not covered at the pharmacy under the drug formulary).
Download (253KB)
Dental Claim Form
This form is to be used when seeking reimburement of dental claims or estimation of dental procedures.
Download (100KB)
Long-Term Disability - Employee Application
This packet is needed for those applying for long-term disability.
Download (234KB)