Sorry, you need to enable JavaScript to visit this website.
Skip to main content

Plan Forms

Forms marked with an asterisk * are fillable. That means you can complete the form on your computer. Once complete, print and sign the form and send it to the Plan.

You will need Adobe Acrobat Reader to view and complete any forms. These forms work best with Google Chrome or Firefox web browsers.

Check out our helpful checklists and forms below:

Employer Forms

Employer's Statement Part A*

Employer's Statement Part B*

Rehabilitation Earnings Statement*

Enrolment Form*

Accumulation of the Qualifying Period on a Non-Consecutive Basis (85 Sick Days) (2023-2024)

Coverage While on Leave of Absence or Layoff*

Employee Forms

DIP Employee Application Checklist

Employee's Statement*

Attending Physician's Statements (Select the correct form for your physician to complete.)

The group plan number for the following forms is 57402.

Initial Attending Physician's Statement - Cancer Form*

Initial Attending Physician's Statement - Cardiac Form*

Attending Physician's Statement - Mental Health Conditions*

Initial Attending Physician's Statement - Musculo-Skeletal Form*

Attending Physician's Statement - Long Term Disability Claim (Other Conditions)*