Medavie Blue Cross Change Form printable pdf download

CHANGE FORM

THIS AREA MUST BE COMPLETED FOR CHANGES TO BE PROCESSED

644 MAIN ST PO BOX 220 MONCTON NB E1C 8L3

Existing Identification Number

7 SPECTACLE LAKE DR DARTMOUTH PO BOX 2200 HALIFAX NS B3J 3C6

FOR ALL INQUIRIES: TEL 1-800-667-4511 FAX (506) 867-4651

Existing Policy and Section Number

Last Name

Instructions:

Earnings information is only required if life and/or income replacement benefits apply.

Employer to forward original and keep second copy.

The Optional Group Life Insurance Statement of Health form must be completed when an ADD or CHANGE is requested for

Optional Life benefits. The actual amount of coverage must be stated (not the amount of the increase / decrease).

TYPE OF CHANGE - CHECK ( )

Address

Marital Status

Beneficiary

Left Employ

Cancel Benefits: Reason

Dependent(s)

Retired

Telephone No.

Salary

Add Benefits: Reason

Benefits

Deceased

Occupation

Transfer

Other:

COMPLETE ONLY AREAS AFFECTED BY THE CHANGE AND SIGN

Surname (if

SEX

A-Add

Employee Last Name

BIRTH DATE

Dependent

different from

C-Change

M/F

FIRST NAME

INITIAL

Status

D-Delete

applicant )*

Employee

E- Student

Address (Street & No.)

(College/

University)

Spouse

S-Disabled

Children

City or Town

Province

Telephone No.

(

)

Postal Code

Language Preferred

* IF APPLICANT AND SPOUSE ARE NOT LEGALLY MARRIED, PLEASE PROVIDE

English

French

COMMENCEMENT DATE OF CO-HABITATION

COORDINATION OF BENEFITS

Do you or any of your dependents have other coverage under any other Insurer?

Yes

If Yes, complete the following:

Name of the Other Insurer:

Effective Date of Coverage:

Identification Number/Certificate Number:

Policy Number:

Is the Coordination of Benefits Single Coverage or Family Coverage? Please indicate under "Type of Coverage" S for Single or F for Family for the applicable benefits.

Type of Coverage:

All

Hospital

Extended Health Benefits

Vision

Drugs

Dental

STATUS

BASIC COVERAGE

ADD

CHANGE

DELETE

OPTIONAL COVERAGES

ADD

CHANGE

DELETE

CHANGE

Life (state total amt.)

Employee $

Spouse $

Life

Long Term Disability

Dependent Life

Single

Health

AD & D

Weekly Indemnity

AD&D (state total amt.)

Single

Family

Dental

Critical Conditions

Dependent Child Life

YES

CHANGE OF BENEFICIARY - In accordance with the terms and conditions of the Group Life Contract between the employer indicated below and Blue Cross Life Insurance Company

of Canada, I revoke all previous appointments of beneficiary and hereby appoint the following as beneficiary entitled to receive the proceeds arising by reason of my death.

Beneficiary Last Name

First Name

Initial

Relationship

Percentage

For designated beneficiaries under the age of 18: I appoint

as Trustee to receive any amount due for any beneficiary

considered a minor under the Provincial jurisdiction of residence.

MARITAL CHANGE - When an employee requests a change from single to family coverage within 31 days of marriage, family coverage will become effective as outlined in the Medavie

Blue Cross group benefits contract. If later than 31 days, a statement of health may be required.

Date of change in marital status:

If spouse has Medavie Blue Cross benefits please complete:

Policy Number

Identification Number

Last Name

AUTHORIZATION OF CHANGE - I certify that the information above is accurate and authorize payroll deductions, if required. I authorize Blue Cross to collect, use and disclose my

personal information as described in the Privacy Statement on the reverse of this form.

Employee Signature

Witness Signature

Date

TO BE COMPLETED BY EMPLOYER

Name of Employer

Policy and Section Number Class of Coverage - Health Employee Class - Life and/ Occupation

and/or Dental

or Disability Income

Effective Date of Change

Complete for Life and Disability

Hours