Group Benefits Enrolment Application Form
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1
2
3Group Benefits
Enrolment or Re-enrolment Application
Please print clearly and complete all pages of form. If required, retain a photocopy for your files.
1 Plan sponsor statement
Plan contract number
Account/Division number
Billing division (if applicable)
Plan member certificate number
To be completed by plan
Plan sponsor name
Plan sponsor telephone number
sponsor.
(
)
Enter member's certificate number,
Provide permanent full time hire date
If a re-hire, provide the date previous employment
Re-hire date (dd/mmm/yyyy)
if known. Otherwise leave blank for
(dd/mmm/yyyy)
ended (dd/mmm/yyyy)
Manulife Financial to complete.
Do you want the waiting period added to the permanent full time hire date?
Yes
No
Plan member's occupation
Class
Regular hrs./week
Annual earnings
$
Is evidence of insurability required?
In order to determine if evidence
Yes
No
of insurability is required, please
If evidence of insurability is required, plan members must complete GL0004E, Evidence of Insurability,
refer to your contract.
and send it to Manulife Financial for processing. Manulife Financial will not contact your Plan
Administrator to verify that this form has been mailed.
2 Plan member information
Plan member name (last, first, middle initial) (please print)
Date of birth (dd/mmm/yyyy)
We require this information to
enrol you in the plan.
Sex
Province of residence
Language of preference
Male
Female
English
French
3 Plan member address
Address (number, street, apt. number)
City
Province
Postal code
Applying for Health and Dental Benefits
4
Applying for coverage
Health
Dental
Note: You may refuse benefits for
Myself ONLY
yourself and your dependant(s)/
spouse ONLY if you are covered
Myself AND 1 dependant/spouse
for similar benefits under your
Myself and 2 or more dependants/spouse
spouse's plan. If you wish to add
this coverage at a later date you
None, because my spouse has coverage
may re-apply for these benefits.
Dependant Life
Satisfactory medical evidence
Note: If you have eligible dependants, refusal of
may be required.
Yes
No
this benefit is not allowed on an AlphaPlus plan.
5 Coordination of benefits
Effective date (dd/mmm/yyyy)
Spousal Health
Does your spouse have health coverage
Yes
No
Coverage
under his/her own insurance plan?
If you do not have a spouse,
this section does not apply.
Spousal Dental
Does your spouse have dental coverage
Effective date (dd/mmm/yyyy)
Yes
No
Coverage
under his/her own insurance plan?
This information is important
Does your spouse's health/dental plan cover:
for the correct adjudication of
your claims.
Health
Dental
Your spouse only
Your spouse and yourself only
Spouse's date of birth (dd/mmm/yyyy)
Your spouse and children only
Your spouse, you and your children
Do you have a
If common-law spouse,
Date (dd/mmm/yyyy)
Yes
No
common-law
provide the date the
spouse?
co-habitation commenced.
6 For Quebec residents
I am participating in the RAMQ drug plan provided by the Quebec government
(age 65 or over)
I am NOT participating in the RAMQ drug plan provided by the Quebec government
The Manufacturers Life Insurance Company
Page 1 of 3
GL2971E (09/2007) GP/MC
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