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Benefits Forms

Health and Dental Claim Forms

Clinical Faculty

• Claim Forms

CUPE 2692 and IUOE 772

• Extended Health Care Claim Form - use this form to seek reimbursement for extended Health and Dental claims, including Vision Care.
• Group Benefits Dental Claim Form - if your dentist does not directly bill Manulife on your behalf, have the dentist enter the claim information on this form.

UWOFA, UWOFA-L&A, CUPE 2361, PMA, UWOSA, SAGE, °ÄÃÅÁùºÏ²Ê¿ª½±Ô¤²â Special Constable Service (OPSEU) and Postdoctoral Associates

• Extended Health Care Claim Form - use this form to seek reimbursement for extended Health and Dental claims, including Vision Care, and reimbursement from your Health Care Spending Account.
• Group Benefits Dental Claim Form - if your dentist does not directly bill Manulife on your behalf, have the dentist enter the claim information on this form.

Retirees

• Extended Health Care Claim Form - use this form to seek reimbursement for extended Health and Dental claims, including Vision Care.
• Group Benefits Dental Claim Form - if your dentist does not directly bill Manulife on your behalf, have the dentist enter the claim information on this form.

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Other Benefit Forms

• Taxable Wellness Spending Account (WSA) Form — UWOFA only
• Benefit Application/Change Form - use this form to add or remove benefit coverage, and to change beneficiaries for life insurance plans.
• Safety Shoe and Insole Reimbursement Form
• Private Duty Nursing Claim Predetermination Submission Guidelines

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Educational Assistance Forms

• Application for Educational Assistance for Librarians and Archivists
• Application for Educational Assistance for Regular Full-time Staff
• Course Book Reimbursement

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