Quick Contact
Ottawa office
466 Tremblay Road
Ottawa, ON K1G 3R1

Tel: 613-231-2266
Fax: 613-231-2345
Toll Free: 1-888-613-1234
Winnipeg office
1403 Kenaston Boulevard
Winnipeg, MB R3P 2T5

Tel: (204) 942-4438
Fax: (204) 943-5998
Toll Free: 1-888-204-1234

Forms

Pre-authorized payment form

With pre-authorized payment you don't have to write cheques to cover your group insurance plan premium payments.  Payments can be made automatically through your bank or financial institution account.

Complete and sign the Pre-authorized payment form. Return it to the Coughlin office that has been paying your claims.

You must provide either:

  • a void cheque; or
  • a fully encoded deposit slip from your bank from which the necessary account and coding information can be obtained.

Pre-authorized payment form

employee benefits specialists
Important forms
Dental - Medical Claim Forms
Dental & medical claim forms
Pre-authorized deposit forms
Pre-authorized deposit forms
Pre-authorized payment forms (Ottawa only)
Pre-authorized payment forms (Ottawa only)
If you share our dedication of providing Service Beyond Expectations™...
Personal financial programs for you and your family.
What's new
March 30, 2020
UPDATE: COVID-19 Coughlin & Associates Ltd. is act...