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Below, you’ll find all Employee forms organized by type. The forms on this page are for administrative and claims purposes, and in most cases, will include requisite instructions and corresponding mailing addresses.

How to use and submit forms

Save the forms to your computer. In some cases, you can fill them in directly before printing. Otherwise, print them out and complete them by hand before mailing to the address indicated.

All ENROLLMENT forms must be mailed to NEBS

MAIL

NORTHERN EMPLOYEE BENEFITS SERVICES 
#700, 5201 50TH AVENUE, NORTHWEST TOWER
YELLOWKNIFE NT X1A 3S9

All DENTAL, VISION  AND EXTENDED HEALTH CLAIMS forms should be mailed to the Co-operators or submitted online via the link in the sidebar

MAIL

Co-operators Life Insurance Company 
Extended Health Care Claims
1920 College Avenue
Regina, SK S4P 1C4

Employee Information Change Forms

Employee Information Change Form - Group Insurance & Health Benefits
Change Your Address, Name, Spousal Information, Dependent Information, Plan Coverage
Employee Information Change Form - Pension
Change Your Name, Spousal Information, Dependent Information
Employee Address Change Form - Pension
Change Your Pension Address
Notice of Employee Salary Changes
Salary Changes for Health and Pension
Notice of Employee Leave
Notice of Employee Leave for Health and Pension
Declaration of Common-Law Spouse
Common-Law Declaration Form
Declaration of Beneficiary - Group Insurance & Health Benefits
Group Insurance & Health Benefits Beneficiary
Declaration of Beneficiary - Pension
Pension Beneficiary
Declaration of Student Eligibility - Group Insurance & Health Benefits
Use if Dependent Child is in School - Over 21 Under 25
Declaration of Student Eligibility - Pension
Use if Dependent Child is in School - Over 18 Under 25
Employee Acknowledgement of Extended Heath & Vision and Dental Benefits
Acknowledgement That You Have 30 Days From Effective Date to Enroll Without Penalties
Application for Direct Deposit - Pension
Complete This Form if You Want Your Pension Direct Deposited
Statutory Declaration
Can be Used for Declaring an Adopted Child - Contact Office for Required Information

Additional Coverage Applications

Optional Life Insurance Rate Sheet
Rate Sheet for Optional Life Insurance
Optional Life Insurance Application
Use to Apply for Optional Life Insurance
Pensioner Retirement Health Benefits - Plan Summary
Plan Summary for Pensioner Retirement Health Benefits
Pensioner Retirement Health Benefits - Application
Use to Apply for Pensioner Retirement Health Benefits
Retirement Health Benefits for Non-Pensioners - Brochure
For Retirement Health Benefits for Non-Pensioners
Retirement Health Benefits for Non-Pensioners - Rate Sheet
Rate Sheet For Retirement Health Benefits for Non-Pensioners
Retirement Health Benefits for Non-Pensioners - Application
Use to Apply For Retirement Health Benefits for Non-Pensioners
Retirement Health Benefits for Non-Pensioners - Surviving Spouse Application
Use if You are a Surviving Spouse of a Non-Pensioner
Retirement Health Benefits for Non-Pensioners - Change Form
Use to Change Already Submitted Information
Health & Dental Plan Conversion - Brochure
Use for Converting Group Benefits to an Individual Plan
Health & Dental Plan Conversion - Rate Sheet
Use for Converting Group Benefits to an Individual Plan
Health & Dental Plan Conversion - Application
Use for Converting Group Benefits to an Individual Plan

Extended Health and Dental Claim Forms

Extended Health Care Claim Form
Use for Extended Health and Vision Claims
Dental Claim Form
Use for Dental Claims
Emergency Out of Country Claim and Authorization Form
Use for Emergency Out of Country Claims
Adverse Reaction Form
Use to Report Adverse Reactions (Side Effects)
Request for Brand Name Drug Coverage
To be Eligible There Must be Medical Evidence an Adverse Reaction has Occured
Direct Deposit Application for Health Care/Dental Claims
Use to Have Your Claim Direct Deposited