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Below, you’ll find all of our Member 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

Enrollment Forms

Employee Enrolment Form for Pension AND Group Insurance & Health Benefits
Both Pension & Group Insurance & Health Benefits Enrolment
Employee Enrolment Form for Group Insurance & Health Benefits Only
Group Insurance & Health Benefits Enrolment Only
Employee Enrolment Form For Pension Only
Pension Plan Enrolment Only
Elected & Appointed Officials Enrolment Form
Elected & Appointed Officials Enrolment Only
New Employer Application for Participation in Insurance & Health Benefits Plan
New Employer Application for Participation in Pension Plan
Employer Application for Termination of Participation in Insurance & Health Benefits Plan
Employer Application for Termination of Participation in Pension Plan
Employee Acknowledgement of Employer's Intent to Terminate - Health or Pension
Employer Application to Change Insurance & Health Benefits Plan Coverage
Health Evidence Questionnaire

Employee Information Change Forms

Employee Information Changes - Group Insurance & Health Benefits
Change Your Address, Name, Spousal Information, Dependent Information, Plan Coverage
Employee Information Changes - Pension
Change Your Name, Spousal Information, Dependent Information
Employee Address Change - 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
Employee Discontinuance Form
Use this form for Employee employment termination
Employee Declaration of Common-Law Spouse
Declaration of Beneficiary - Health
Declaration of Beneficiary - Pension - Final
Employee Declaration of Student Eligibility - Health
Employee Declaration of Student Eligibility - Pension
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 - Blank

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

Basic Life Claim Forms

Notice of Death - Claimant Statement
Notice of Death - Plan Sponsor Statement
Proof of Death - Physician Statement
Living Assistance Plan Member Agreement and Application

Accidental Death Disease and Dismemberment Claim Forms

Authorization to Obtain Information - Deceased
Authorization to Obtain Information - Claimant
Employer-Administrator Statement Accidental Death & Dismemberment
Proof of Accidental Death Attending Physician's Statement
Proof of Accidental Death Claimant Statement
Proof of Loss Dismemberment Claim - Attending Physician's Statement
Proof of Loss Dismemberment Claim - Claimant's Statement

Disability Claim Forms

Short Term Disability Plan Member Guide and Application
Short Term Disability Plan Sponsor Statement
Short Term Disability Attending Physician Statement
Short Term Disability - Return to Work Notice
Long Term Disability Plan Member Guide and Application
Long Term Disability Plan Sponsor Statement
Long Term Disability Attending Physician Statement
Long Term Disability - Return to Work Notice

Extended Health and Dental Claim Forms

Extended Health Care Claim Form
Dental Claims Form
Emergency Out of Country Claim and Authorization Form
HC Vigilance Adverse Reaction Reporting Form
Request for Brand Name Drug Coverage
Direct Deposit Application for Claims