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 below.
Forms can be emailed to: info@nebsnorth.com
All original forms must be mailed to the NEBS Office
NORTHERN EMPLOYEE BENEFITS SERVICES
5122 - 53 STREET
YELLOWKNIFE, NT X1A 1V6
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
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
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
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