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Weekly Indemnity Claim

Use
You've become disabled (through injury or sickness) and are no longer able to work. Use the Weekly Indemnity Benefits Claim form to make your claim for Weekly Indemnity benefits.



Information Needed to Complete the Form
Your personal Member information is needed to complete the form. The policy number, 9000 must be included on the form. In addition, information such as:

  • details of the sickness and/or accident,
  • your employer's statement and signature,
  • the physician's contact information, and
  • the attending physician's statement and signature
is also required.

Please follow the instructions on the form.


Notes
  • Your claim must be filed within 30 days of becoming disabled.
  • Both your employer and your doctor must complete their sections of the form before the claim will be considered.
  • The Member must sign on both pages of the form.
Questions on completing the form should be directed to the Plan Administrator.

Completed forms should be sent to the Plan Administrator.


Plan Administrator
Millworkers Health & Welfare Plan (Unifor) Administrator
c/o D.A. Townley
160 – 4400 Dominion Street
Burnaby, BC V5G 4G3

Phone: 604-299-7482 or 1-800-663-1356
Fax: 604-299-8136

Email: Health
 

Form Link
Weekly Indemnity Benefits Claim Form
( PDF - 97 Kb)
 

Related Links
Weekly Indemnity Benefit Information
 
 
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