Forms

Note: The Employee Benefits Application form (20057) and the Employee Benefit Changes form (20058) should now be used instead of the Beneficiary appointment/change form and the Health and Dental benefit application and change forms.

Orthopedic shoe and foot orthotic fabrication form/medical supply checklist (ABC 83475)

When claiming for orthopedic shoes, foot orthotics or surgical stockings, plan members should view this fabrication form and medical supply checklist.

Contact information change form (ABC 83046)

Use this form to notify us when administrators are added, changed or remove, or to update contact information.

Health and Dental Benefit Application (ABC 20064)

Submit this form to add eligible employees (that is, those who have fulfilled the requirements of the Group Contract.)

Health and Dental Changes (ABC 20065)

Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group Contract.

Employee Benefits Application (ABC 20057)

Submit this form to add eligible employees (i.e. those who have fulfilled the requirements of the Group Contract.)

Employee Benefit Changes: (ABC 20058)

Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group Contract.

Over-Age Dependent Declaration (ABC 30230)

Submit this form to declare

  • an unmarried child over the dependent age but under the maximum age specified in the Group Contract who is attending an accredited educational institution on a full-time basis, or
  • an unmarried child, over the dependent age as specified in the Group Contract, but fully dependent due to mental or physical infirmity.
Preauthorized Debit (PAD) Agreement (ABC 80415)

The Preauthorized Debit (PAD) Agreement form gives us permission to take monthly payments from your account. After completing the form, please attach a cheque marked "Void" to it, sign it, and fax or mail it to us at the address on the form. If you have already arranged for your payments to be withdrawn automatically from your account, but need to change your bank, or bank account information, you may use this form.

Statement of Account Reconciliation (ABC 30187)

Submit this form to outline your monthly premium payment.

Life and disability forms

Application for Benefits - Employer's Statement (ABC 30714)

Notice of Return to Work (ABC 30134)

Early Notice Form (ABC 30715)

Application for Benefits – Employee’s Statement (ABC 31317)

Attending Physician’s Statement – General (ABC 31043)

Death Claim Form (ABC 30298)

Job Description (ABC 30135)

Motor Vehicle Accident Questionnaire (ABC 30339)

Direct Deposit Form for Disability Benefits (ABC 31385)

Education and Work History (ABC 30297)

Early Return to Work Form (ABC 31551)

Additional information

  • Did you know that you can use your keyboard to type into the fields on all the forms?
  • If a fill-in area is active (contains a blinking bar) the contents will not print. Make sure to use your mouse to select a non-active area of the form before printing.
  • Print and sign the form. Be sure to attach any additional supporting documentation or original receipts where required. Mail it to Alberta Blue Cross at the address indicated on the form.
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