Request to Deduct and Pay a One-time Retroactive Payment to an Insurer

This form is for use by disability insurance companies who have a valid Approval Deduction and Payment Agreement with the Minister of Human Resources and Social Development Canada and who are seeking a reimbursement from Service Canada for CPP Disability benefits paid to you while you were receiving benefits from your insurer for the same period. This form contains a statutory declaration which requires the insurer to declare that they are acting in accordance with the terms and conditions of the Approval Deduction and Payment Agreement.