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
175 Hargrave Street, Suite 100
Winnipeg, MB R3C 3R8

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
December 12, 2017
Ontario Government Launching OHIP+: Children and Youth ...
July 04, 2017
Thinking about a career at Coughlin & Associates Lt...
March 17, 2017
Watch our video about how Coughlin can help service you...
February 24, 2016
Check out the newest Coughlin Courier. (PDF 296 KB)