Benefit forms

This page contains forms for the public service group insurance benefit plans: the Public Service Health Care Plan (PSHCP), the Public Service Dental Care Plan (PSDCP), the Pensioners’ Dental Service Plan (PDSP), the Public Service Management Insurance Plan (PSMIP) and the Disability Insurance Plan (DI).

• Application form for active and retired members
• Prior Authorization form
• Claim forms (regular and out-of-country)
• Veterans Affairs Canada Application and Amendments forms

The PSHCP Relief Provision application form is found on the Public Services and Procurement Canada website.

Here you can access forms for the Public Service Dental Care Plan (PSDCP).

• Claim Form for Public Service Dental Care Plan (PSDCP) (PDF Document – 155 KB) (The Canada Life Assurance Company)
• Public Service Dental Care Plan (PSDCP) - Authorization for Claims Submission and Redirection of Payment (PDF Document - 80 KB) (The Canada Life Assurance Company)
• Public Service Dental Care Plan (PSDCP) Dependant Information Form (PDF Document - 130 KB) (The Canada Life Assurance Company)

Here you can access forms for the Pensioners’ Dental Services Plan (PDSP).

• Claim Form (PDF Document - 54 KB - Sun Life Financial)
• Pensioners’ Dental Services Plan (PDSP) Authorization for Claims Submission and Re-direction of Payment Form

Note: If you are about to retire, you can obtain the Pensioners’ Dental Services Plan (PDSP) form (used to enrol, amend or terminate PDSP coverage) from the Government of Canada Pension Centre. If you are already retired or become entitled to a survivor benefit, you can obtain the PDSP form from the Pension Centre.

Here you can access forms for the Public Service Management Insurance Plan (PSMIP).

• The four claim forms for the Public Service Management Insurance Plan - Long-Term Disability (PSMIP-LTD) benefits can be found on the Industrial Alliance PSMIP-LTD website. They include the:
  • Employee’s Statement (F54-1011A-57)
  • Attending Physician’s Questionnaire (F54-1014A-57 for a mental health condition), or (F54-1015A-57 for a musculoskeletal condition), or (F54-1016A-57 for all other medical conditions)
  • Employer’s Statement (F54-1012A-57 to be completed by the immediate supervisor or manager)
  • Employer’s Statement (F54-1013A-57 to be completed by departmental compensation/Human Resources advisor)

  The Disability Insurance Plan claim forms below can be found on the Sun Life DI webpage: www.sunlife.ca/DI.

  • Employee’s Statement (490L-M-12500-E)
  • Attending Physician’s Questionnaire (490L-P-12500-GEN-E, 490L-P-12500-MHC-E, or 490L-P-12500-MSK-E)
  • Employer’s Statement (Immediate Supervisor or Manager)(4841-E)
  • Employer’s Statement (Compensation Advisor)(4811-E)