Printable Forms: FNIS Group Insurance, Long Term Disability Claim Forms
The following four forms must be completed, signed and forwarded to First Nations Insurance Services’ office for processing in order to make a claim for Long Term Disability Benefits.
Plan Sponsor’s Statement—Claim for Long Term Disability Benefits
- When requested, Plan Sponsor must complete this form, sign and return it to First Nations Insurance Services office for processing.
Plan Member’s Statement—Claim for Long Term Disability Benefits
- When requested, Plan Member must complete this form, sign and return it to First Nations Insurance Services office for processing.
Attending Physician’s Statement—Long Term Disability Benefits
- When requested, Plan Member must have their Licensed Physician or Specialist complete this form, sign and return it to First Nations Insurance Services’ office for processing.
Authorization to Release Information
- When requested, Plan Member must sign this form and return it to First Nations Insurance Services’ office for processing.
The following two forms are required instead of the forms listed above only when requested by FNIS.
Plan Sponsor's Statement-Disability Transition Form
- Only when requested, Plan Sponsor must complete this form, sign and
return to the First Nations Insurance Services' office for processing.
Plan Member's Statement-Disability Transition Form
- Only when requested, Plan Member must complete this form, sign and
return to the First Nations Insurance Services' office for processing.
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