Medical Plan Forms

SIU Resources & Forms
SIU MEMBER RESOURCES – MEDICAL AND DENTAL CLAIM FORMS
 
SIU MEDICAL PLAN CONTACT INFORMATION

SEAFARERS’ MEDICAL PLAN
200 – 1333 rue St-Jacques
Montreal, Quebec, H3C 4K2

Tel: (514) 931-0550
Fax: (514) 931-3667
Toll-Free: 1 (855) 605-0550

Attention: Lyne Leblanc
Email: medical@seafarers.ca


Claiming Care Benefits Form

CLAIMING CARE BENEFITS FORM
Form to be completed if claiming for hospital, medical, dental care or vision care benefits. To print or save this form in .PDF format, please click this link below.
Claiming Care Benefits Form



Reimbursement Form

REIMBURSEMENT FORM
Reimbursement of prescribed medication and injections. To print or save this form in .PDF format, please click this link below.
Reimbursement Form



Wage Loss Benefits Form

WAGE LOSS BENEFITS FORM
Form for claiming short term wage loss benefits or if you wish to have your disability period counted as a sailing period. To print or save this form in .PDF format, please click this link below.
Wage Loss Benefits Form



Dental Claim Form

DENTAL CLAIM FORM
Standard dental Claim Form: To print or save this form in .PDF format, please click this link below.
Dental Claim Form



Death Benefits Form

DEATH BENEFITS FORM
Standard Death Benefits form: To print or save this form in .PDF format, please click this link below.
Death Benefits Form



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