Fillable Plan Member Confirmation of Illness Form (Desjardins Insurace)

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Plan Member Confirmation of Illness Form (Desjardins Insurace)

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The Plan Member Confirmation of Illness Form (Desjardins Insurace) form is 2 pages long and contains:

  • 1 signature
  • 12 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

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1. Please confirm:
(dd/mm/yyyy)
2. Please indicate the symptoms associated with
yo
ur illness:
Fever Decreased appetite
Cough Runny nose
Fatigue Nausea
Muscle aches Vomiting
Sore throat Headache
Shortness of breath
Other
3. Do you
have
an
y other health problems that might affect your recovery (e.g. diabetes, heart disease, respi
ratory
illness)?
Plan Member Confirmation of Illness Form
Please only complete this form if your absence is due to symptoms of COVID-19 and you're pending
test results, or if you have a clinical diagnosis of COVID-19.
In recognition of the increasing pressure on our medical clinics and hospitals due to the COVID-19 pandemic, we
will not, at the outset, require an Attending Physician’s Statement as part of your disability claim submission if
your absence is due to COVID-19 symptoms, or a clinical diagnosis of the virus. This is a time limited exception
as we move through the current situation.
In the absence of an Attending Physician’s Statement, we require confirmation of your symptoms, your test
results, and any medical treatment you may have received for your condition. Accordingly, please complete and
sign this form and return it, along with the required supporting documents, using our secure page, at
desjardinslifeinsurance.com/send.
STD Form for COVID-19
Policy number:
Plan Member Name:
Date symptoms first appeared
:
First
day absent from work:
Certificate Number:
Plan Sponsor Name:
(dd/mm/yyyy)
Contact us:
1-800-463-7843 (toll free)
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
7. Any other details relating to your illness you'd like us to know:
I certify that the statements in this form are true and complete and understand that further information may be
required to validate my claim.
Phone #: Cell #:
Name:
STD Form for COVID-19
4. A) Date of medical consultation relating to COVID-19:
(dd/mm/yy)
B) Who was the medical consultation with (e.g.: physician/clinic/hospital/Public Health authority)?
C) Test result:
Positive
Negative
Pending - if pending, date expected:
Attach test results if available.
6. Have you been instructed to quarantine?
Yes, as of this date:
No
(dd/mm/yyyy)
• When do you expect the quarantine to
end?
• When are you next seeing your physician?
• When do you expect to return to work?
• Can you work from home?
Yes
No
5. A) Date of COVID-19 test:
B) Name, ad
dress and
p
hone number
of
facility
where
test
conducted.
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
(dd/mm/yyyy)
Email
Signature:
Date:
Have questions about your claim? Contact the Customer Contact Center at 1-800-463-7843 (toll free).
For more information on the novel coronavirus, go to the Public Health Agency of Canada’s website at https://
www.canada.ca/en/public-health.html
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Plan Member Confirmation of Illness Form (Desjardins Insurace)

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Completed 9 February 2021

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