As of January 1, 2018, please use the following plan numbers and forms for Blue Cross Dental and Health
ACTIVE EMPLOYEES - 91389-F
RETIREES - 91392-F
- BLUE CROSS DENTAL CLAIM FORM
- BLUE CROSS EXTENDED HEALTH CARE CLAIM FORM
- BLUE CROSS MANDATORY GENERIC SUBTITUTION EXCEPTION REQUEST
- NON GENERIC FORM (SIDE EFFECT REPORTING FORM)
PDF versions of Medical, Dental, Functions Ability Form (FAF)and WI Claim forms are now available to download and print. Mailing addresses are on the bottom of this page.
Medical Plan # 85020 for active members, Division # 73. Use these numbers for all Manulife and Blue Cross Health Claims.
As of January 1, 2017, the Company requires all members with a NEW Weekly Indemity or Long Term Disability Claim, to file their claim with BLUE CROSS. Forms are below.
Dental Plan #85021 for active members, Division # 73
Medical Plan #85080 for Retired members
Click on the link below to download and print. The files are in Acrobat PDF format.
Also there are Dental & Health writeable PDF versions available.
Please remember to keep a copy of anything that you send to the insurance company. Any problems or rejected claims, please see the union office!
- Manulife Dental Claim Form
- Manulife Writeable Dental Claim Form
- Manulife Extended Health Care Claim Form
- Manulife Writeable Extended Health Claim Form
- Manulife Weekly Indemnity Claim Form
- NEW - BLUE CROSS* Attending Physician Form -
- Take this form to your Doctor for Weekly Indemity & LTD claims as of January 1, 2017.
- NEW - BLUE CROSS* Employee Claim Form -
- Members are required to fill out this form for Weekly Indemity & LTD claims as of January 1, 2017.
- Functions Ability Form (FAF)
(Health claims): (Dental claims): New WI & LTD claims as of January 1, 2017 :
Manulife Financial Manulife Financial Blue Cross
Group Health Claims Group Dental Claims Weekly Indemity & LTD Claims
PO Box 1653 PO Box 1654 PO Box 668, Station B
Waterloo, Ontario Waterloo, Ontario Montreal, Quebec
N2J 4W1 N2J 4W2 H3B 3K3