Group Benefits Enrolment Form Page 2
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Complete Group Benefits Enrolment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
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Banking details
If you wish to have your Extended Health Care and/or Dental Care benefit payments deposited directly into your bank account, attach a void
cheque, direct deposit form or bank verification statement.
If you do not have a chequing account, you must provide a direct deposit form or bank verification statement from your bank branch.
This form must be provided by your bank, trust company, caisse populaire or credit union in Canada, and be signed and stamped by a
banking representative. If your bank provides an online direct deposit form, pre-populated with your banking information, this can also be
submitted. These forms must contain your name, the Bank Number, your Branch Number and Account Number to facilitate your benefit
payment being deposited directly into your account.
Please attach a void cheque, direct deposit form or bank verification statement
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Spouse details –
complete this section only if you are applying for coverage for your spouse
Spouse’s last name
Spouse’s first name
Date of birth (yyyy-mm-dd)
Gender
Male
–
–
Female
Is your spouse covered for Extended Health Care and/or Dental Care benefits by his/her employer’s plan?
No
Yes
If yes, please indicate spouse’s coverage:
Extended Health Care
Family
Single
Dental Care
Family
Single
Name of benefits carrier:
_________________________________________________________________________
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Children details –
complete this section only if you are applying for coverage for your children
Over-age
disabled
Gender
Student*
child**
Child’s last name
Child’s first name
Date of birth (yyyy-mm-dd)
Male
Yes
Yes
–
–
Female
No
No
Child’s last name
Child’s first name
Date of birth (yyyy-mm-dd)
Male
Yes
Yes
–
–
Female
No
No
Child’s last name
Child’s first name
Date of birth (yyyy-mm-dd)
Male
Yes
Yes
–
–
Female
No
No
Child’s last name
Child’s first name
Date of birth (yyyy-mm-dd)
Male
Yes
Yes
–
–
Female
No
No
* A student is a child age 21 or over but under age 25, who is a full-time student attending an educational institution recognized by Canada
Revenue Agency, as long as the child is not married or in any other formal union and is entirely dependent on you for financial support.
(For Quebec plan members, please check with your plan administrator for dependent student age limit.)
** To enrol an over-age disabled child, complete a Disabled Child Coverage form, and send it to us within 31 days of the date the dependent
reaches the age limit.
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942-2755-BI-08-13
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