Forms ("1stchoice" Benefit Plans) To be used by Government of Alberta, Management and Non-Union Employees. Enrolment/Change Form Use this form to select and/or change benefit coverage as well as to enroll or remove dependents. Statutory Declaration Form Use this form when a Statutory declaration is required (generic in nature). Statutory Declaration - Eligible Benefit Recipient Use this form to enroll a Eligible Benefit Recipient in the group benefit plans. This form must be completed when an Employee has cohabited with their Eligible Benefit Recipient between 24 and 36 months. Claim Form - Health Services (including Extended Medical & Prescription Drugs) Use this form to submit claims for all health benefit products or services. Claim Form - Dental Use this form to submit claims for all dental services and procedures. Claim Form - Emergency Out of Country Expenses Use this form to submit claims that occurred outside of Alberta/Canada due to a medical emergency. Note, must have selected the Enhanced Medical Coverage in order to be eligible for Emergency Travel Plan coverage. Long Term Disability Income Continuance Plan - Employee's Statement Use this form to apply for Long Term Disability Income Continuance Plan benefits. Group Life Insurance - Evidence of Insurability Form Use this form to apply for Enhanced Life Insurance or to increase the level of Enhanced Life Insurance. Some conditions apply. Group Life Insurance - Application & Declaration for Non-Smoker Rate Use this form if you are a non-smoker and are applying for Enhanced Life Insurance. Group Life Insurance - Application for Conversion Use this form to convert the group life insurance to an individual policy without providing evidence of insurability upon termination of employment, retirement or at reaching age 70. NOTE: This form must be submitted to Great-West Life within 31 days of the loss of coverage. Group Life Insurance - Designation of Beneficiary Form Use this form to designate beneficiary(ies) for Group Life Insurance. Group Life Insurance - Advance Payment Use this form if the Employee is terminally ill and wishes to request an advance payment from their life insurance proceeds. Part I of this form must be completed by the Employing Ministry and Part II is by the Employee. Group Life Insurance - Advance Payment - Attending Physician's Statement Use this form if the Employee is terminally ill and wishes to request an advance payment from their life insurance proceeds. This form must be completed by the Employee’s Physician. Group Life Insurance - Claim for Accidental Dismemberment or Loss Use this form if claiming for accidental dismemberment or loss of use. Part I of this form must be completed by the Employing Ministry and Part II by the Employee. Group Life Insurance - Certificate of Attending Physician - Accidental Dismemberment or Loss Use this form if claiming for accidental dismemberment or loss of use. This form must be completed by the Employee’s Attending Physician.

• Home
• Privacy

• Contact Us
• Search
• International Travel Expenses

© 1995 - 2012 Government of Alberta Copyright and Disclaimer