Use this form if you were injured in an accident to provide the details and circumstances of the accident as part of your Short or Long Term Disability application.
Complete this form once a year as part of your employee statement. This form allows us to gather information on your behalf for your short-term or long-term disability application.
ONLY for Blue Choice ® and Personal Choice plans. Use this form to add a dependent to your Blue Choice ® or Personal Choice Plan who is more than 30 days old.
Use this form to add a spouse or dependent to your Blue Assured ® , Seniors Plus Plan or Health Plus plan. This form is also used to add a newborn under 30 days of age to a Blue Choice ® or Personal Choice Plan.
Use this form to detail your job description and responsibilities when applying for Short or Long Term Disability benefits.
When applying for Short or Long Term Disability benefits, this form must be completed by your employer and outlines job duties and responsibilities.
This form must be filled out by your physician and provides additional information regarding your Long Term Disability benefits application.
This form must be filled out by your physician and provides additional information regarding your Short Term Disability application.
This form must be filled out by your physician and provides additional information regarding your Critical Illness claim application.
Use this form to submit an Accidental Dismemberment claim. This form contains sections that must also be filled out by your physician to provide additional information regarding your Accidental Dismemberment application as well as by your employer.
Use this form to submit an Accidental Dismemberment claim. This form contains sections that must also be filled out by your physician to provide additional information regarding your Accidental Dismemberment application.
The baggage claim form can be used to submit expenses for lost, stolen, damaged or delayed baggage.
Use this form to assign or update your beneficiaries. A beneficiary receives payment from your Life Insurance and/or Accidental Death and Dismemberment plan if you pass away.
Use this form to apply for a Critical Illness benefits. Please note you will also need to provide a completed Attending physician statement for Critical Illness form also found on this page.
If you are submitting a Short Term Disability claim for an absence related to the coronavirus and do not have an attending physician statement, we require you use this form to confirm your symptoms and any medical treatment you may have received for your condition.
Use this consent form if you are 18 years of age or older and want Alberta Blue Cross ® to provide personal health information to another individual. You may, for example, want Alberta Blue Cross ® to provide your personal health information to another adult (such as your spouse, child, a relative, a friend or a lawyer). If the person who is the subject of the information request is incapable of making personal decisions or of understanding or signing the form, please contact our Customer Services department for a different consent form.
Submit this form to add or change access of a plan administrator or users access to the Alberta Blue Cross website for plan administrators to conduct transactions on behalf of the policyholder.
This form is used to submit all dental claims including accidental dental services.
Your employer must fill out this form when you are moving from Short to Long Term Disability benefits. This form helps us work with other carriers to create a pending Long Term Disability file.
When on Long Term Disability benefits, six months prior to the two-year term, complete this form to provide information on your education and work history. This will help us put together a plan for retraining or returning to work.
Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group’s Contract.
Submit this form to add eligible employees (such as those who have fulfilled the requirements of the Group’s Contract.)
This form is a fabrication form that must be filled out by your healthcare provider for custom orthotics.
This form is a fabrication form that must be filled out by your healthcare provider for custom orthotics. (Government of the Northwest Territories)
Submit this form to add eligible employees (such as those who have fulfilled the requirements of the Group’s Contract.)
Submit this form to report any changes to an existing employee's status. These changes must adhere to the Group’s Contract.
This form is used to submit claims for products or services such as prescription drugs, private or semi-private hospital accommodation, ambulance, psychology services, physiotherapy, chiropractic, wheelchairs, vision care and hearing aids.
If you have a health spending account, you may use this form to submit eligible medically-related claims for reimbursement through it. The types of claims that you may submit through your account are described in detail on the claim form.
This form is used to request reimbursement of your health or dental plan rates. It must be submitted along with a health spending account claims form, and must be signed by your employer.
Submit this form to change the payment arrangement for your health spending account.
Complete this form to make your beneficiary irrevocable. An irrevocable beneficiary receives payment from your Life Insurance and/or Accidental Death and Dismemberment plan if you pass away. They cannot be removed as your beneficiary without their written consent.
Your employer must fill out this form detailing your position and duties as part of your application for Short or Long Term Disability benefits.
Use this form to submit a Life Insurance or Accidental Death claim. Please note that this form contains sections that will need to be filled out by your employer.
Use this form to submit a Life Insurance or Accidental Death claim.
Only for personal plan members
This slip may be used to submit eligible claims for reimbursement through this program.
Submit this form to declare
The Preauthorized Debit (PAD) agreement form gives us permission to take monthly payments from your account. After completing the form, please attach a cheque marked "Void" to it, sign it and fax or mail it to us at the address on the form. If you have already arranged for your payments to be withdrawn automatically from your account, but need to change your bank or bank account information, you may use this form.
Submit this form to arrange to have payments for Non-Group Coverage (group 1) automatically withdrawn from your bank account.
Submit this form if you want to change previous banking information or give permission for Alberta Blue Cross ® to withdraw monthly payments FROM your account and TO directly deposit claims to the same or different bank account. Or, save time and stamps by registering for direct deposit online through the member site.
Use this form to remove a dependent from your personal health and dental plans.
Submit this online form to request replacement ID cards or a copy of your plan contract. We'll send the documents you requested within 10 business days via Canada Post. Save time by registering for direct deposit online through the member site.
Submit this form to arrange to have your claim payments deposited directly into your bank account or to change the banking information we have on file for you.
Submit this form to outline your monthly premium payment.
Only for personal plan members
Travel insurance medical emergency claim forms
Choose the form that applies to you to submit expenses.
Travel refund request
To request a travel refund, call us:
Monday to Friday
8:30 a.m. to 5 p.m. (MT)
1-800-394-1965 and select option 4
The trip cancellation or interruption claim form can be used to submit expenses for a cancelled or interrupted trip.
Complete this form with your irrevocable beneficiaries signature to remove or change their designation. Once removed, you can submit a new beneficiary or irrevocable beneficiary form to update your beneficiaries.
Use this form if you already know the expense categories used by your benefit plan.
Sorry, there are no forms that match these criteria.
Your claim may be eligible for online submission. Save time and paper with contactless claiming on our member site today.
Head office
10009 108 St NW
Edmonton, Alberta
T5J 3C5
We begin by acknowledging that we are on traditional lands, referred to as Treaty 6, Treaty 7 and Treaty 8 territory, and all the people here are beneficiaries of these peace and friendship treaties.
This territory is the home for many Indigenous Peoples, including the Blackfoot, Cree, Dene, Saulteaux, Ojibwe, Stoney Nakota Sioux, and Tsuut’ina peoples, and the Métis Nation of Alberta and the Métis Settlements.
We respect the Treaties that were made on these territories, we acknowledge the harms and mistakes of the past, and we dedicate ourselves to moving forward in partnership with Indigenous communities in a spirit of reconciliation and collaboration.
©Copyright 2024 ABC Benefits Corporation. All rights reserved. ®* The Blue Cross ® symbol and name are registered marks of the Canadian Association of Blue Cross Plans ® , an association of independent Blue Cross ® plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan ® . ®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association.
Life, disability and travel insurance plans are underwritten by various underwriters. For information, visit ab.bluecross.ca/underwriters.
Alberta Blue Cross ®Head office
10009 108 St NW
Edmonton, Alberta
T5J 3C5
We begin by acknowledging that we are on traditional lands, referred to as Treaty 6, Treaty 7 and Treaty 8 territory, and all the people here are beneficiaries of these peace and friendship treaties.
This territory is the home for many Indigenous Peoples, including the Blackfoot, Cree, Dene, Saulteaux, Ojibwe, Stoney Nakota Sioux, and Tsuut’ina peoples, and the Métis Nation of Alberta and the Métis Settlements.
We respect the Treaties that were made on these territories, we acknowledge the harms and mistakes of the past, and we dedicate ourselves to moving forward in partnership with Indigenous communities in a spirit of reconciliation and collaboration.
©Copyright 2024 ABC Benefits Corporation. All rights reserved. ®* The Blue Cross ® symbol and name are registered marks of the Canadian Association of Blue Cross Plans ® , an association of independent Blue Cross ® plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan ® . ®† Blue Shield is a registered trade-mark of the Blue Cross Blue Shield Association.
Life, disability and travel insurance plans are underwritten by various underwriters. For information, visit ab.bluecross.ca/underwriters.