Accidental dismemberment and specific loss
How to make a claim
If you have coverage through your employer or plan sponsor, use these forms to make an accidental death or dismemberment claim.
To make a claim, follow these steps:
Step 1: Complete a claim form.
Download the form and print it or fill it out in Adobe Reader XI or higher - Opens in a new window (not your browser) and save. You’ll need your employer to fill in some sections.
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Use this form to apply for accidental dismemberment or specific loss benefits.
Step 2: If applicable, complete a claim form for any supplementary benefits.
Download the form and print it or fill it out in Adobe Reader XI or higher - Opens in a new window (not your browser) and save. You’ll need your employer to fill in some sections.
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Use this form to apply for supplementary benefits with an accidental dismemberment or specific loss claim.
Step 3: Request a completed physician’s report.
Ask your doctor to complete this form.
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Use this form to provide information from your doctor about your accidental dismemberment or specific loss claim.
Step 4: Submit your claim.
You can email your completed forms to grouplifebenefits@canadalife.com or fax them to 204-946-8783.
In light of COVID-19, we ask that you do not mail these forms to us.
Not the forms you're looking for? Go back to the find a form page.