Optional Spouse And Dependent Group Life Insurance Election Form
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1
2OPTIONAL SPOUSE AND DEPENDENT
GROUP LIFE INSURANCE ELECTION
This form is used to select basic insurance coverage for
your spouse and/or dependents.
For optimum accuracy, please
See the instruction page for further details.
print in capital letters and avoid
When completed, mail to your pay office. Your pay
contact with the edge of the box.
office will forward to the Benefits Service Centre.
PART A - EMPLOYEE INFORMATION
EMPLOYEE LAST NAME
FIRST NAME
MINISTRY / EMPLOYER
SOCIAL INSURANCE NO.
DEPARTMENT ID (MIN - PAYLIST)
EMPLOYEE ID
-
-
EMPLOYEE BIRTHDATE
YYYY
MM
DD
/
/
PART B - COVERAGE ELECTION / EMPLOYEE AUTHORIZATION
Instructions:
Mark only one of the following boxes with an X, fill in the Date Signed field, and provide your Signature.
Please enroll me in optional spouse and dependent group life insurance.
I do not want this coverage. (Evidence of insurability may be required if you enroll at a later date.)
I wish to cancel this coverage.
EMPLOYEE SIGNATURE
DATE SIGNED
YYYY
MM
DD
/
/
PART C - MINISTRY / EMPLOYEE CONFIRMATION OF ELIGIBILITY (if Enrollment requested)
Instructions:
Mark only one of the applicable 'Reason for request' boxes with an X and complete the corresponding effective date below.
Became Regular
Payroll Date Stamp
Became Auxiliary with benefits
Acquired first dependent
DATE BECAME ELIGIBLE/ACQUIRED FIRST DEPENDENT
YYYY
MM
DD
/
/
PART D - MINISTRY / EMPLOYER CERTIFICATION
Instructions:
Please complete and sign. Mail original form to the Benefits Service Centre.
AREA CODE
PAY OFFICE FAX NO.
AREA CODE
PAY OFFICE TELEPHONE NO.
(
)
-
(
)
-
CERTIFIED CORRECT - PRINT NAME (PAY OFFICE OFFICER)
PAY OFFICE SIGNATURE
DATE SIGNED
YYYY
MM
DD
/
/
BCPSA 41 Rev. 2014 / 09 /
25
34372
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