Service Canada – Insurer: Disability Benefits Retroactive Payment and Information Sharing Consent.

This form is used by persons applying for a Canada Pension Plan Disability benefit who are in receipt of monthly disability benefits from their private insurer. If you are granted and signed Consent A of this form it gives Service Canada permission to reimburse your insurer a one-time payment, which covers the period of time you were entitled to disability insurance benefits and CPP Disability benefits. In other words, this eliminates a payment you would otherwise owe to your insurer. Once signed, Consent A cannot be cancelled. If you are granted and signed Consent B of this form, it allows your insurer to give Service Canada your Insurance Policy and client identification numbers and the date when your disability insurance benefits started so that your CPP Disability retroactive reimbursement payment is correctly applied to your account. It also allows Service Canada to give your insurer the information they need to adjust their future monthly payment to you. If you do sign, keep a copy for your records and send the original to the insurer who will send to Service Canada.