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FNIS PRINTABLE FORMS |
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For your convenience, we have put a number of Insurance forms on this site that you can print. Be sure to read the description provided for each form carefully, to ensure you are accessing the proper form. If a required form is not found on our website, or you are unsure of which form you should be using, please contact us at (306) 242-8008.
Adobe Acrobat Reader is required to view these forms. To get Adobe Reader click below:
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Once a form is completed, please return it to:
First Nations Insurance Services Ltd.
P.O. Box 2377
Prince Albert, SK
S6V 6Z1
website: www.firstnationsins.com |
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FNIS GROUP INSURANCE ASSOCIATION PLAN |
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| FNIS GROUP INSURANCE ASSOCIATION PLAN APPLICATION / DATA CHANGES |
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| A new employee of a participating employer must complete this form upon becoming eligible to participate in their group insurance plan. A separate application must be completed for each class of employment. If an employee takes a leave of absence, the employee must complete a new application upon returning. This form can be used for subsequent changes to an employee’s personal information such as name change, marital status change, dependent status or if the employee wishes to make changes to beneficiary designation(s) or trustee designation(s). Any beneficiary/trustee designations require the employee signature, date, as well as a witness signature, other than a named beneficiary. DO NOT use whiteout in Section C of this form. If the employee’s spouse has an Extended Health and/or Dental and/or Vision plan equal to or better than their employer plan, they can opt out of the applicable benefit. Subsequently, if the employee’s spouse terminates employment with their employer and no longer have EH/D/V benefits, the employee can opt back in to member’s EH/V/D plan within 31 days of their spouse’s termination. The plan administrator can use this form to report salary changes, transfers between divisions (if they have more than one division) and terminations. |
| FNIS Plan Group Insurance Application /Data Change Form |
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| FNIS GROUP INSURANCE EXTENDED HEALTH / VISION AND DENTAL CLAIM FORMS |
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| Standard Group Dental Claim Form
- Plan Member and member’s Dentist must complete this form and submit it to First Nations Insurance Services’ office for processing. Any orthodontic services require a treatment plan. For dental services over $300 the member’s dentist should provide a dental pre-authorization.
Extended Health Benefits Claim Form
- Plan Member must complete this form and submit it for processing along with original (paid in full) health expense and/or vision expense receipts to First Nations Insurance Services’ office.
Application for Emergency Out of Saskatchewan Hospital/Medical Expenses Claim Form
- Plan Member and member’s Physician and/or Specialist must complete this form and submit it to First Nations Insurance Services’ office for processing along with original receipts.
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| FNIS GROUP INSURANCE - SHORT TERM DISABILITY |
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| FNIS GROUP INSURANCE - LONG TERM DISABILITY CLAIM FORMS |
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| The following six forms must be completed, signed and forwarded to First Nations Insurance Services’ office for processing in order to make a claim for Long Term Disability Benefits. |
| Plan Member’s Statement—Claim for Long Term Disability Benefits
- When requested, Plan Member must complete this form, sign and return it to First Nations Insurance Services office for processing.
Authorization to Communicate Information Canada Pension Plan
- When requested, Plan Member must complete this form, sign and return it to First Nations Insurance Services office for processing.
Deduction and Payment of Canada Pension Plan (CPP) Disability Benefits to an Administrator of a Disability Income Program
- When requested, Plan Member must complete this form, sign and return it to First Nations Insurance Services’ office for processing.
Attending Physician’s Statement—Long Term Disability Benefits
- When requested, Plan Member must have their Licensed Physician or Specialist complete this form, sign and return it to First Nations Insurance Services’ office for processing.
Authorization to Release Information
- When requested, Plan Member must sign this form and return it to First Nations Insurance Services’ office for processing.
Plan Member's Statement-Disability Transition Form
- Only when requested, Plan Member must complete this form, sign and
return to the First Nations Insurance Services' office for processing.
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| STAFF ONLY PRINTABLE FORMS |
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| OTHERS |
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Copyright
© 2007 Athabasca Catering Limited Partnership. All rights reserved. |
