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.Group information, plan administrator or online access change form (GR18-025)
Use this form to notify us when there is a change to group information, if a plan administrator needs to be added or removed or to add, update or remove plan administrator online access.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.
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 If you have already arranged for your payments to be withdrawn automatically from your account, but need to change your bank, or bank account information, you may use this form.Statement of Account Reconciliation (ABC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
- 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.