Find a Form

This section contains the forms related to your BCPSEA Benefits Program coverage. To access some of these forms, you will need Adobe® Acrobat® Reader® . You can download this software for free from Adobe’s web site if you do not have it already installed on your computer.

• BCPSEA Benefits Enrolment Form
• BCPSEA Benefits Change Form
• BCPSEA Optional AD&D Application
• BCPSEA Optional Life Application
• Waiver of Coverage Form
• Smoker Declaration Form
• Common Law Spouse Declaration Form
• Notice of Leave Form
• Notification of Conversion Form
• Contingent Beneficiary Form

• PBC Extended Health Claim Form
• PBC Dental Claim Form
• Extended Health and Dental Conversion Forms
• PBC Statement of Health
• Application for Waiver of Life Premium Claim forms
  • Premium Waiver Benefits Application
  • Premium Waiver –  Employee Statement for Teachers – (Life)
• Emergency Out-of-Province Claim form
• Return to Work Notice form

For Life or AD&D claims, please contact your Benefits Administrator.

• Life Insurance Claim forms
  • PBC Living Benefit Claim Form
  • Life Claim Form
  • Dependent Life Claim Form

For the conversion of group insurance to (an) individual plan(s), the Benefits Administrator will provide you with a Notification of Conversion Form and Group Life Conversion Privilege Notification Form to advise you of which benefits you are eligible to convert and the time limits for converting each benefit. If you are eligible for Life conversion please contact Pacific Blue Cross for conversion information.

For AD&D conversion information please contact AIG Insurance Company of Canada. If you are eligible for extended health and dental coverage conversion, please use the conversion forms provided on this page.