Disability Income Plan Forms

Forms marked with an asterisk * are fillable. That means you can complete the form on your computer. Once complete, print and sign the form and send it to the address indicated below:

Please submit completed documentation to:
Public Employees Benefits Agency, Disability Benefits
110 – 1801 Hamilton Street
Regina, SK Canada S4P 4W3



You will require Adobe Acrobat Reader to view and complete any forms. These forms work best with Google Chrome or Firefox web browsers. 

Check out our helpful checklists below:

DIP_employee application checklist

DIP_employer application checklist


Attending Physician's Statements

The group plan number for the following forms is 57402.