1. Member Statement
The Member Statement asks questions about your demographic information, information about your job, your disability and/or medical conditions, and any income/benefits that you may be eligible to receive. The requested information is needed to assess your claim. Please complete all questions in the Member Statement and ensure you review, sign and date the form.
Other Required Documents:
Authorizations
HEB Manitoba needs your authorization to collect the information necessary to assess and manage your claim for D&R Benefits. When you sign the enclosed authorization forms, HEB Manitoba can request the necessary information from your physician, your employer, and other relevant sources. To obtain more information about your privacy, please visit the Privacy section.
Income Tax Deduction Form
D&R Benefits are taxable. The Income Tax Deduction Form must be completed and signed even if you choose not to have income tax deducted.
If you want income tax deducted, indicate either a percentage rate or a flat dollar amount to be deducted. If you require assistance to calculate your income tax deduction, contact the Canada Revenue Agency. HEB Manitoba cannot calculate this amount for you.
Electronic Funds Transfer Form
If your claim is accepted, D&R Benefits are paid by direct deposit through your financial institution into an account in your name. To identify the account and to confirm that it is your personal account, you must provide one of the following:
Or
Note: As D&R Benefits must be provided to the claimant, the account that you identify for HEB Manitoba to deposit your D&R Benefits into must be in your name. D&R Benefits are not assignable.
Proof of Age
To confirm your age, provide a photocopy of one of the following documents:
Updated Resumé
Provide an updated copy of your resumé, if available.
2. Attending Physician's Statement
The Attending Physician’s Statement may be completed by a:
Note: The professional who completes the Attending Physician’s Statement must be providing care and treatment for your claimed medical condition and must be legally qualified and lawfully entitled to practice according to the laws of Manitoba, and cannot be related to you by blood or marriage.
Please supply your Physician with a signed Patient Authorization/Confidentiality Agreement Form (enclosed with your application), which will allow your Physician to provide the necessary medical information to HEB Manitoba. Please ensure that your Physician submits the completed original form prior to the application deadline.
You are responsible for providing medical evidence to prove that you are eligible to receive D&R Benefits. If the forms are not fully completed, your claim assessment will be delayed, and your eligibility for benefits may be affected.
If your Physician charges to complete the Attending Physician’s Statement, you are responsible for paying the fee.
3. Employer Statement
Your employer will complete this form to provide information regarding your last day worked, the physical and psychological demands of your job and other information needed to assess your claim.
To assist you, HEB Manitoba will send the Employer Statement directly to your employer for completion. Your employer will provide a copy of your job description, and HEB Manitoba will follow up with your employer regarding the Employer Statement and job description. However, you are responsible for ensuring the Employer Statement is received by HEB Manitoba.