Forms

Online claim submission is available via RWAM Plan Member Services.

Download and print these PDF forms for paper claim submission.

Should you have questions about which form to use, or need assistance filling out a form please contact RWAM.

Claim Forms

Health and Dental Claims

 Extended Health Care Claim (RC001)

 Formulaire de Demande de prestations d'Assurance maladie complémentaire (RC001F)

 Dental Claim - use the Canadian Dental Association Standard Dental Claim Forms

Out-of-Canada / Out-of-Province Travel Claims

 Out-of-Canada / Out-of-Province Claim Submission Summary

 Out-of-Canada / Out-of-Province Claim Form

 Formulaire de demande de règlement Frais médicaux pour les Canadiens à l’extérieur du pays ou de la province

Specialty Forms for Claims

 Attending Physician's Statement (RC027)

 Brand Name Drug Exception (for Mandatory Generic Plans only) (RC054)

 Formulaire pour médicaments de marque d'exception (pour les régimes avec option obligatoire de substitution des médicaments) (RC054F)

Health Spending Account (HSA) Claims

 HSA - Stand Alone (RC002)

 CCS - Version distincte - français (RC002F)

 EHC/HSA - 1 Certificate (RC020b)

 EHC/HSA - 2 Certificates (RC020)

 AMC/CCS - 2 certificats - français (RC020F)

Coordination of Benefits

 Coordination of Benefits Form (RA104)

 Coordination des prestations (RA104F)

Update Personal Information

 Employee's Direct Deposit of Group Benefit Payments (RA014)

 Demande de dépôt direct de prestations d'Assurance collective (RA014F)

 Change in Status / Name / Primary Beneficiary (RA077)

 Changement d'état civil / de bénéficiaire / de nom (RA077F)

 Beneficiary Designation / Change (RA086)

 Changement/Désignation de bénéficiaire (RA086F) 

 Irrevocable Beneficiary Designation (RA182)

 Désignation de bénéficiaire irrévocale (RA182F)

 Declaration of Student Eligibility (RA042)

 Out-of-Province/Canada Coverage Extension Request for Student Study/Work Term (RA100)

 Déclaration d'admissibilité à titre d'étudiant (RA042F & RA100F)

Critical Illness

Contact your Plan Administrator or contact RWAM for Critical Illness claims assistance.

Disability

Contact your Plan Administrator or contact RWAM for Disability claims assistance.

Health Evidence

RWAM offers products through a variety of carriers. Please refer to the provider page of your Employee Benefits Booklet, contact your Plan Administrator, or contact RWAM to determine which carrier's Health Evidence form to use

 Health Evidence - RWAM (RU035)

 Déclaration d'assurabilité (collective) - RWAM (RU035F)

 Health Evidence - RBC

 Assurance collective Formulaire de preuve d'assurabilité - RBC

Group Life Conversion

For individuals leaving a company who wish to convert their existing Group Life coverage to an Individual Life Insurance Policy. Please refer to the provider page of your Employee Benefits Booklet, contact your Plan Administrator, or contact RWAM to determine which carrier's Group Life Insurance Conversion form applies to you.

• Group Life Insurance Conversion - La Capitale - Contact RWAM for a quote

 Group Life Insurance Conversion - RBC

Plan Administrator Forms

Plan Administrators, download forms for administering the Group Benefit Plan from the Plan Administrators Forms page.

Stop Waiting for your Money - Submit your Claims Electronically

Find out how by visiting the Claim Submission Guidelines page.