Active Members | Forms

Disability Self Pay Extension Form

Coverage Details

Description

Disabled and unable to work? Complete the Disability Self Pay Extension form to request to self pay for benefit coverage.

Applicable for

Member Only

Submit your form online:

Step 1

Download, print and fill out the form.

Download Form

Step 2

Upload the form using our online submission form.

Upload Now

Submit by mail:

LiUNAcare Local 506
3750 Chesswood Drive, Suite 1
Toronto, ON M3J 2W6

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Disability Self Pay Extension Form

Coverage Details

Submit your form online:

Submit by mail:

Get Mobile Access to Your Benefits

Check Out Our Mobile Apps

Contact Information

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Disability Self Pay Extension Form

Coverage Details

Submit your form online:

Submit by mail:

Get Mobile Access to Your Benefits

Check Out Our Mobile Apps

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