Employment And Salary Change Form
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1Group Benefits
Employment and/or Salary Change Form
Mail completed and signed forms to:
Plan number
Manulife Financial
Group Benefits, Plan Member Administration
PO Box 1627, Waterloo On N2J 4P4
New
New
New
Account
Certificate
Date of change
Reason
Return date
**Salary
New
New
New
Last name
First name
salary
billing
province of
number
number
(dd/mmm/yyyy)
code*
(dd/mmm/yyyy)
frequency
occupation
class
account
amount
division
residence
**Please fill in the total new salary
*Please use reason code as shown. Not required for salary, occupation, class, account, billing division or province changes.
amount and Frequency as follows:
Code
Definition
T
Termination
Code
Definition
R
Retired or Pensioned
A
Annual
LA
Layoff/Complete Termination of Benefits
M
Monthly
LB
Temporary layoff of less than or equal to 120 days with continuation of all benefits. Ensure ’Return date’ is specified.
S
Semi-annual
LC
Temporary layoff of less than or equal to 120 days with termination of Disability benefits. Ensure ’Return date’ is specified.
B
Bi-weekly
LD
Indefinite layoff greater than 120 days with termination of Disability benefits but with continuation of other benefits up to 120 days.
W
Weekly
Reinstatement may only be selected if it is within the reinstatement period outlined in your contract, and if benefits are the same as at layoff/termination.
RE
If reinstated outside of reinstatement period, and/or benefits are different, completion of Enrolment/Re-enrolment form is required.
Signature of Plan Administrator
Date signed (dd/mmm/yyyy)
This form is available on Manulife’s ’Plan Administrator Secure Site’. Go to to register for site access and more information.
GL3644E (09/2003)
The Manufacturers Life Insurance Company
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Parent category: Business