Benefit forms

The Public Service Health Care Plan forms are found on the PSHCP Member Services website

List of forms available:

• 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.

Access Public Service Dental Care Plan (PSDCP) forms on the PSDCP Member Services website with Canada Life:

• claim forms (regular and out-of-Canada)
• authorization and redirection form
• application for dependant with a disability form
• PSDCP Positive Enrolment Form
• PSDCP direct deposit form

PSDCP coverage starts exactly three months from the date you become an eligible plan member.

Access Pensioners’ Dental Services Plan (PDSP) forms on the PDSP Member Services website with Canada Life:

• claim forms (regular and out-of-Canada)
• authorization and redirection form
• Application for Dependant with a Disability Coverage form
• PDSP Positive Enrolment Form
• PDSP direct deposit form

To apply for the PDSP, contact the Government of Canada Pension Centre to get the Pensioners’ Dental Services Plan form. This form is also used to amend or terminate coverage.

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)
• PSMIP Claim Form for Accidental Dismemberment Benefit (Forms number TBS 5954 & 5955)
• PSMIP Claim Form for Death Benefit (Forms number TBS 5948 & 5949)
• Form 2027 - Long-term Disability Insurance – PSMIP PWGSC
• Form 2027-1 - Long-term Disability Insurance – PSMIP (Part-time Employee Only) PWGSC
• Form 2028 - PSMIP PWGSC
• Form 2028-1 - PSMIP (Change of Name or of Beneficiaries) PWGSC
• Form 2028-5 - PSMIP Part-time employee only PWGSC
• Form 2028-7 - PSMIP – Members Entitled to Government-Paid Coverage PWGSC
• Form 2451-1 - Post-retirement Life Insurance Plan (Change of Name/Change of Beneficiary)

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)