Form Msi 378 - Bcbs Application For Benefits Employee Statement
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1
2APPLICATION FOR BENEFITS
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EMPLOYEE STATEMENT
Page 1 of 2
PO Box 4030 Saskatoon SK S7K 3T2
306.244.1192 Toll-free in Saskatchewan 1.800.667.6853
Fax 306.652.5751
Complete the fields below with accurate information to the best of your ability. It is an offence to make a false or misleading
statement in an application for benefits. Missing or inaccurate information could result in a delay in processing your application.
Notify Saskatchewan Blue Cross of any changes that may affect your eligibility for benefits, including an improvement in your
medical condition, a return to work, and/or entry into training or rehabilitation programs.
Name ________________________________________________________________
Male
Female
Last
First
Initial
Date of Birth
I
I______
Social Insurance Number ____________________________________ ______
YYYY
MM
DD
Address ________________________________________________________________________________________________
Street/PO
Town
Province
Postal Code
Telephone ______________________________________ Email Address ___________________________________________
What is the nature of your medica l condition? ___________________________________________________________________
If your condition is due to an accident, provide details including date. ________________________________________________
_______________________________________________________________________________________________________
What is the current treatment? ____ __________________________________________________________________________
What medication are you currently taking? ______________________________________________________________________
State the reason(s) this condition is preventing your return to work. _________________________________________________
_______________________________________________________________________________________________________
Have you ever had a similar condition?
Yes
No
If yes, state when and provide details. ___________________________
_______________________________________________________________________________________________________
Do you have any other medical condition(s) at this time?
Yes
No
If yes, describe. ______________________________
When do you expect to return to work? ______________________________________________________________________ _
Provide the name of the physician who is currently providing treatment for this condition, and the name of all medical practitioners
who have treated you in the last 3 years. (Please attach a list if more space is required.)
Physician or Hospital
Reason
Date of First Visit
Date of Last Visit
Name and Location
YYYY|MM|DD
YYYY|MM|DD
Are you receiving or have you applied for accident or disability benefits from other sources, e.g., CPP/QPP, your provincial
workers’ compensation authority, automobile insurance, insurance companies, government agencies?
Name of Source
Date of Application
Benefit Amount
Frequency of
Benefit Start Date
Benefit End Date
YYYY|MM|DD
Payment
YYYY|MM|DD
YYYY|MM|DD
®Saskatchewan Blue Cross, Blue Cross, Blue Cross Life Insurance Company of Canada and 1-800-USEBLUE are registered trade-marks of the Canadian Association of Blue Cross Plans, used
under license by Medical Services Incorporated, an independent licensee.
MSI 378 09/13
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