FORMS

Drug and Supplementary Health Care Claim

Use this form for any drug or supplementary health (such as physiotherapy, hearing aids, etc) or emergency medical travel insurance claims.

Bereavement Claim

Use this form if you encountered wage loss at the time of death of a family member.

Parental Leave Claim

Use this form if you encountered wage loss at the time of the birth/adoption of your child(ren).

Dollar Bank Account Freeze

Use this form to have your dollarbank frozen while you are receiving wage loss benefits from one of the following sources:

- EI Maternity or Parental or Compassionate Care benefits

- WSIB

- Income replacement benefits from your private insurance provider as a result of a MVA.

Private Duty Nursing Care Pre-Approval

This form should be to initiate a pre-authorization process for IUOE Local 793 Plan to cover private nursing expenses.

Dismemberment Benefit Claim

This form must be used if you a suffered a dismemberment within 365 days of an accident that occurred any time of the day, on or off the job.

Dental Claim

This form should be used for any dental claims.

Health Care Spending Account

This form should be used if you have covered, out-of-pocket medical and dental expenses that exceed your Active Benefits Plan coverage.

Group Legal Claim

Use this form for the reimbursement of legal services set out in the current schedule of benefits up to the maximum amount indicated.

Jury Duty or Subpoenaed Witness

Use this form if you encountered wage loss if you were on jury duty or a subpoenaed witness.

To update your personal, dependant, and beneficiary information, please fill-out the Request for Personal Information Form by accessing this link: Request for Personal Information Form (PIF)

Personal Information Form (Staff)

If you are a staff of Local 793, please contact HR to update your personal, dependant, and beneficiary information.

Request for Payment by Direct Deposit (EFT)

Use this form to update your banking information to deposit your claim/benefit payment directly into your bank account. This form can be mailed or dropped off in person.

Erectile Dysfunction Drugs

Use this form to initiate the prior authorization process for erectile dysfunction drugs (i.e. Cialis, etc.), to be reviewed and considered for coverage under the IUOE Local 793 Plan. All claims for these drugs require prior approval at least once every 12 months.

GLP-1 Medications

Use this form to initiate the prior authorization process for GLP-1 medications (i.e. Ozempic, etc.), to be reviewed and considered for coverage under the IUOE Local 793 Plan. All claims for these drugs require prior approval at least once every 12 months.

All Other Forms

Use the link below to access forms to initiate the prior authorization process for specialty drugs used to treat complex medical conditions through the FACET Program. Completed forms can be submitted via fax to FACET at 1-844-446-1575.

https://www.facetprogram.ca/en/

Short Term Disability Claim

Use this form to start your claim for disability benefits.

Appeal to Trustees' Appeal Committee

This form is to be used if you want to appeal the decision of a claim.