FORMS

Claim Forms (click on the form and follow the link to The Co-operators)

Extended Health and Dental

• Dental Claim Form

• Extended Health Claim Form

• Direct Deposit Application - Health Care/Dental Payments

           Disability Claim Forms (click on the form and follow the link to The Co-operators)

           Please be sure to fully complete the employer, employee and
           physician statement and send to Matrix Benefit Services.

• Direct Deposit Application - Disability Benefit Payments

• Employers Guide to disability claims

• Return to work notice

  Short Term Disability/Weekly Indemnity

• STD/WI Employee Statement

• STD/WI Physician Statement

• STD/WI Employer Statement

  Long Term Disability

• LTD Employee Statement

• LTD Physician Statement

• LTD Employer Statement

Life Claim Forms - Please call Linda for more information.

• Completed forms should be sent to MATRIX.

Administration Forms (in PDF format)

• Cost Plus Claim Form

• Matrix Enrollment or Change form

• Group Policy Change Form

• Designation/Change of Beneficiary Form

• Health evidence – contact Amber

Broker Forms (in PDF format)

• Enrollment Procedures

• Master Application

• Matrix Enrollment or Change Form

• Health evidence – contact Amber