Fillable Employee Change Form printable pdf download

EMPLOYEE CHANGE

Mailing Address:

for PBC office use only

Group Number(s) of Plans to be Changed

PO Box 7000, Vancouver, BC V6B 4E1

Dental Care

Extended Health

BC Life

Street Address:

4250 Canada Way, Burnaby, BC

Fax: 604 419-2990

First Name

Surname

Middle Initial

ID Number (e.g. S.I.N.)

Name of Company/Organization

Effective Date of Employee Change

(mm/dd/yy)

Employee Change: Check all relevant boxes and provide requested information

Name Change

Employee’s former name _________________________________________________________________________________

Address Change

New address ____________________________ City ______________________ Province ______ Postal Code __________

Salary Change

New salary __________

Hour

Week

Bi- Weekly

Month

Year

Number of hours worked per week ____

BC Life Division Change New division ____________________________________

New sub-division _______________________________________

Class/Payroll Change

New class _________________ New department number/Section ID _______ New employee number __________________

Occupation

(required for class change) ___________________________________________________________________________________

Employment Type Change __________________________________________________________________________________________________

Terminate Employee

Date(mm/dd/yy) _____________

Reason for termination _____________________________________________________

Transfer Employee

Terminate from EHC/Dental group number _____________________ Add to EHC/Dental group number __________________

Reason for transfer ____________________________________________________________________________________

Dependent Change: Check all relevant boxes and provide requested information

Add

Change

Terminate

the Dependent(s) listed below:

If adding a spouse:

Date of marriage __________________

Date of cohabitation __________________

(mm/dd/yy)

If any of your dependents were covered under another plan within the past 6 months, indicate the following:

Insurance company _______________________________________

Benefits

EHC

Dental

Group/Policy number(s) ____________________ ID number ______________________________ Termination date

(mm/dd/yy) ________________________________

Surname*

First Name

Middle Initial

Birth Date

**See instructions below

Dep.

Sex

Termination Date

for required information

(mm/dd/yy)

(* not required if same as yours)

**IN SPACE PROVIDED ABOVE:

• handicapped child - give nature of disability

• adopted child - give date of adoption

1) If you are adding:

2) If you are terminating dependent(s) - give reason.

• a dependent - give relationship to employee (If you are adding a

legal ward, attach copy of court document.)

3) If you are changing dependent’s name - give former name

• student over plan age limit (19 or 21), give name of school

I hereby declare that all the information provided in this application is true and complete. I consent to the personal information provided above being retained,

used and disclosed in accordance with Pacific Blue Cross/BC Life’s privacy policy.

Note: A copy of the Privacy Policy is contained in your benefits booklet. It is also available on our Web site at or from your employer.

Signature of employee

Date(mm/dd/yy)

Signature of employer

Date(mm/dd/yy)

™ Pacific Blue Cross, the registered trade-name of PBC Health Benefits Society is an independent licensee of the Canadian Association of Blue Cross Plans.

® BC Life is the registered trade-name of British Columbia Life & Casualty Company, a wholly–owned subsidiary of Pacific Blue Cross.

0553.001 30-20-201 11/09 ACES TEST

CUPE 1816