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.
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.
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.
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.