APPLICATION FOR BENEFIT PLANS MEMBERSHIP

New Application

Evidence of Insurability

A. EMPLOYEE INFORMATION (Complete in all cases.)

Name: Miss

Mrs. Ms. Mr
(last name)

Employee I.D. #: Sex: F

(first name)

(middle initial)

Date of Birth: . Status: Full-time

Part-time

(DD-MM-YY)

B. BENEFIT COVERAGE STATUS

To be eligible for benefits coverage you and/or your dependants must be covered under a Provincial Health Insurance
Plan.

Extended Health Care

Semi-Private Hospital
Dental Care (mandatory unless covered elsewhere)

Single

Family

Waive*

Effective Date: ...

(for office use only)
*I hereby waive my right to enrol in the Benefits listed above. Should I wish to participate at a later date, I will
be required to provide EVIDENCE OF INSURABILITY at my expense.
If you apply for FAMILY coverage more than 31 days after a change in status (i.e. marriage, common-law marriage,
birth or adoption of a child, or your spouse loses his/her coverage (proof is required)), you will require the insurance
companys approval based on evidence of good health for each dependant in your family. Dental coverage for late
entrants will be limited to $250 per individual during the first year of coverage.
If FAMILY coverage is elected, please ensure that you complete section C.

C. DEPENDANT INFORMATION (If FAMILY coverage is elected, please complete)

Spouse:
(last name, first name)

(sex)

(date of birth DD-MM-YY)

Date of Marriage:
If dependant coverage is required for a common-law spouse or same sex spouse, please indicate the date you began
living together: .

Children: Your child(ren) are covered up to the age of 21 (or age 25 if enrolled in university or college on
a full-time basis. Proof of enrollment must be provided on an annual basis or coverage will
terminate)).

(last name, first name)

(last name, first name)

(last name, first name)

(last name, first name)

(sex)

(date of birth DD-MM-YY)

(sex)

(date of birth DD-MM-YY)

(sex)

(date of birth DD-MM-YY)

(sex)

(date of birth DD-MM-YY)

D. CO-ORDINATION OF BENEFITS (Applicable to employees with FAMILY coverage only.)

Co-ordination of Benefits is a method used by the insurance industry to determine the order of paying benefits when
you, your spouse and dependant children are covered under more than one insurance plan. Please refer to your
Benefits Booklet for further details.
i) Does your spouse have coverage for benefits under his/her employer?
If yes, please check ( ) type of coverage:

Health Care

ii) Are you covered under your spouses plan?

If yes, please check ( ) type of coverage:

E.

yes

yes no

Semi-Private Hospital

Dental Care

Semi-Private Hospital

Dental Care

no

Health Care

BASIC LIFE INSURANCE (Applicable to full-time employees only)

Basic Life Insurance is a mandatory benefit with a three (3) month waiting period.
I hereby elect Basic Life Insurance in the amount of:

2 Xs annual salary
Effective Date:
(for office use only)

Beneficiary Designation:

(last name, first name)

(relationship)

(last name, first name)

(relationship)

(last name, first name)

(relationship)

(percent payable)

(percent payable)

(percent payable)

Contingent Beneficiary:

(last name, first name)

(relationship)

(last name, first name)

(relationship)

(percent payable)

(percent payable)

F. LONG-TERM DISABILITY INSURANCE (Applicable to full-time employees only)

Long-term disability insurance (LTD) is a mandatory benefit with a six (6) month waiting period.
Effective Date:
(for office use only)

G. EMPLOYEES SIGNATURE
I hereby apply for membership in my employees benefits plan and authorize the deduction of the appropriate
contributions required by the plan from my earnings, subject to provisions of any law governing designation or change
of beneficiary that may apply. I hereby appoint the above person(s) as my beneficiary to receive any benefits payable
under the Plan that may become due in the event of my death. If there are no surviving beneficiary (ies) at the time of
my death, I declare the above contingent beneficiary (ies) shall receive the proceeds.
I hereby certify that the above information is complete and factual. I also understand that the Hospital reserves the right
to take action and recover any financial loss incurred as a result of misrepresentation or false declaration of information.
Any information regarding benefits listed above is a summary only and the terms of the underlying benefits plans or
policies will govern the employees entitlement. The employer reserves the right to modify or discontinue benefits from
time to time. We will ensure that reasonable notice is given to all employees before such changes go into effect.

SIGNATURE: .

DATE: