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RTIP forms

 
Form Name Form Description
General Claim Submission Form

Complete this form for claims incurred on or after January 1, 2022.

Want to submit your claims online and get your money back faster? Log in to RTIP’s secure member site.

If you need a printed copy of the form, please contact the RTIP Contact Centre at 1-833-318-2811.

Not yet registered on the RTIP plan member secure site? Learn how with these step-by-step instructions
Request for Approval of Brand-Name Drug Form

If your doctor has prescribed a brand name drug instead of a generic brand, because of an adverse reaction or therapeutic failure, they will need to complete this form.

If you need a printed copy of the form, please contact the RTIP Contact Centre at 1-833-318-2811.
 
 

Group Health and Dental forms (not for RTIP members)

 

Claims Forms

Form Name Form Description
Extended Health Benefits Claim Form Complete this form to submit an extended health care expense such as:
  • prescription drugs
  • paramedical (e.g. massage therapist, chiropractor, physiotherapist, etc.)
  • vision care
  • medical aids, equipment and supplies
Standard Dental Claim Form Complete this form to submit a dental claim.
Out-of-Province/Out-of-Country Claim Form Complete this form to submit an out-of-province/out-of-country travel claim.
 

Administrative Forms

Form Name Form Description
Drug Prior Authorization Form OTIP has partnered with Cubic Health's FACET Program to provide members with safe, effective and appropriate specialty drug therapy. Visit pa.otip.com to find the form for your medication.

If you are a CUPE EWBT member, please contact Canada Life at 1-866-800-8058.
Request for Approval of Brand-Name Drug Form Your physician will need to complete this form, if a brand name drug is prescribed instead of a generic brand, because of an adverse reaction or therapeutic failure.
Overage Dependent Student Form If you are a member of one of the Employee Life and Health Trust (ELHT) plans, you can log in to your OTIP secure account to update the status of your overage child as an overage student (if they are eligible).

If you have been directed to use the Manulife’s website to log in, you can access the form here.
Overage Dependent Recertification for coverage If your eligible* overage child is returning to school and needs coverage, you must update your overage child’s student status every year by August 31.

You can log in to your OTIP secure account to update the status of your overage child as an overage student.

*For eligibility, please check your benefits booklet.
Health and Dental Change Form To make changes to your coverage:
  1. Go to www.otip.com, click on Log in and select Health and Dental from the drop-down menu.
  2. Once you have successfully logged in, click on My Benefits.
  3. Click on Enrol/Make changes in My Personal Info box.
  4. Select the appropriate life event.
Pre-Authorized Debit Authorization Form Complete this form to set up or update your form of payment or financial account information for pre-authorized debit, in cases where payment is required for maintaining health and dental benefits.
Application for Insurance and Evidence of Insurability Complete this form to be approved for benefits that require proof of good health.

If you are a member of one of the Employee Life and Health Trust (ELHT) plans, you can log in to your OTIP secure account to complete this form in My Benefits.
 

Long Term Disability (LTD) forms

 
Form Name Form Description
Direct Deposit Authorization for Your Disability Benefit Payments Complete this form to apply for direct deposit for your long term disability (LTD) benefits.
Attending Physician's Statement of Disability - MENTAL Health Conditions As part of your application for long term disability (LTD) benefits, your treating physician(s) and/or specialist(s) must complete the Attending Physician’s Statement of Disability.

Depending on your medical conditions(s), they will need to complete either the (1) MENTAL Health Condition, (2) PHYSICAL Health Condition or (3) both forms.

The completed form(s) must be submitted to OTIP Group Life and Disability Claims at least twelve weeks before your LTD benefits are due (e.g. the expiry of your sick leave).
Attending Physician's Statement of Disability - PHYSICAL Health Conditions As part of your application for long term disability (LTD) benefits, your treating physician(s) and/or specialist(s) must complete the Attending Physician’s Statement of Disability.

Depending on your medical conditions(s), they will need to complete either the (1) MENTAL Health Condition, (2) PHYSICAL Health Condition or (3) both forms.

The completed form(s) must be submitted to OTIP Group Life and Disability Claims at least twelve weeks before your LTD benefits are due (e.g. the expiry of your sick leave).
Appeal Member Statement Form Complete this form to appeal a long term disability (LTD) decision.

If you need more information, please look at our LTD appeal process documentation.
 

Life Insurance forms

 
Form Name Form Description
Group Benefits Life Conversion Option
(Please read the Form Description to learn what steps you need to take before you complete the form.)		 Complete this form to convert your group life insurance to an individual policy.

To start conversion, make sure you do these steps :
 
  1. Review the premium rates on page 2 of the Group Benefits Life Conversion Options form.
  2. If you are still interested, contact Manulife Customer Service Centre at 1-800-268-6195 to calculate your premiums.

    Be sure to tell them that you are calling about the group life insurance conversion option. (NOTE: After you have selected your language preference, select 4 for all others. Do not select 1 for plan member. Your OTIP plan number will not work.)
  3. If you accept the calculated premium rates provided by Manulife, contact OTIP. We will complete the Plan sponsor information section of the form and send it to you.
  4. Fill out sections 2 and 3 of the form.
  5. Send the completed form to Manulife as directed on the form. Manulife will contact you on the status of your application.
Don’t want to provide proof of good health or undergo a medical exam?

Be sure to submit your form to Manulife within 31 days from the date your group life insurance ends or reduces.
Life Claim Form Complete these forms to submit a life claim for the death of an insured party.
Special Advance Payment Complete this form to apply for a Special Advance Payment of your life insurance.

NOTE: You must already have an approved waiver of life insurance premium in place to apply for a Special Advance Payment.
 

Plan Administrator forms

 
Form Name Form Description
Notice of Prolonged Absence To begin the Early Intervention process, complete this form when a member has been off work for 15 consecutive days or more.
Plan Administrator's Statement Complete this form to begin the long term disability (LTD) claim process.
  


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