Change Form - Petsmart Benefits
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1
2
3Group Benefits
Application for Change
Please print clearly and complete all pages of form.
Please complete SECTIONS 1 & 8 for ALL changes and any other sections that are applicable to your change.
If required, retain a photocopy for your files.
1 General information
Plan contract number(s)
Account/Division number
Billing division (if applicable)
Plan member certificate number
We require this information to
process your request.
Plan sponsor
Plan administrator name
Plan administrator telephone number
(
)
Plan member name (last, first, middle initial)
2 Plan member name change
New name (last, first, middle initial)
3
Plan member address
Address (number, street, apt. number)
City
Province
Postal code
Health and Dental Benefits
4 Addition or deletion
of benefits
Addition
Health
Dental
A spouse/common law spouse is
Myself ONLY
considered an eligible dependant
Myself AND 1 dependant
under your group plan. Please refer
to your contract for guidelines.
Myself and 2 or more dependants
My dependants ONLY (I am already covered)
You may refuse Extended Health
Deletion
Care and or Dental Care for
Refuse Extended Health Care
yourself and/or your dependant(s)
only if covered for similar benefits
Refuse Dental Care
under spouse's plan.
Terminate coverage for all dependant(s)
Terminate coverage for specific dependant(s) (see section 6)
If you wish to add coverage at a
I wish to add Dependant Life Insurance
I wish to delete Dependant Life Insurance
Dependant Life
later date you may re-apply for
Reason for addition
Effective date
Reason for deletion
Effective date
these benefits. Satisfactory
(dd/mmm/yyyy)
(dd/mmm/yyyy)
medical evidence may be
required.
Marriage
Divorce
Common-law relationship
Separation
Spouse's coverage cancelled
Coverage with spouse
Other
Other
Please give details of "Other"
In order to determine if evidence
Is evidence of insurability required?
Yes
No
of insurability is required, please
If evidence of insurability is required, plan members must complete GL0004E, Evidence of Insurability, and send it to
refer to your contract.
Manulife Financial for processing. Manulife Financial will not contact your Plan Administrator to verify that this
form has been mailed.
For Quebec residents age 65 or over
I am participating in the RAMQ drug plan provided by the Quebec government
I am NOT participating in the RAMQ drug plan provided by the Quebec government
Page 1 of 3
GL3187E (11/2007) GP/MC
The Manufacturers Life Insurance Company
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