Adminplex Resource Services Inc.
Employee Change Form
30 Kelfield Street
Toronto, ON M9W 5A2
Toll Free: 1.800.565.2467
Fax: 289-304-9052
(This form can be filled in on a device then saved , printed and signed)
Employee's Name:
Save & Print
Clear Form
Policyholder (Employer Name):
Policy Number:
Certificate Number:
Employee Changes:
Effective Date of the Change (mm/dd/yyyy):
New Address:
Name Change: New First Name:_____________________ New Last Name:__________________________
Benefit Coverage Change:
Effective Date of the Change (mm/dd/yyyy):
Change Health Coverage to: Single
Single
Family
Cancel
Change Dental Coverage to: Single
Family
Cancel
Adding/Removing Dependents:
Gender
Date of Birth
S = F/T Student
Effective Date
Add
Remove
Name (First, Last)
Relationship to Insured
(mm/dd/yyyy)
(M/F)
(mm/dd/yyyy)
D = Disabled
Reason For Change*:
*Please indicate the reason you are adding or removing coverage ie. Marriage, loss or gain of spousal coverage, birth/adoption of a child, separation, common
law (must be living together for a full year before your spouse will qualify), etc. U se the actual date of the marriage, birth, legal common law date, etc as the
effective date.
Spousal Coverage Information:
No
Yes
Does your spouse have any other Health or Dental coverage?
If yes, please indicate the following:
Single
Family
Health
Dental
Name of Spouse's Employer
Name of Insurance Company
Policy Number
Beneficiary Change:
Unless otherwise designated, the beneficiary appointment is 'Revocable'. If no beneficiary is designated, the beneficiary will be the estate of the deceased.
Province of Quebec residents, note, the appointment of a spouse as beneficiary is considered 'irrevocable' unless the word 'revocable' is actually written after
the spouse's name.
Name (First, Last)
Relationship to Insured
Percentage %
Contingent Beneficiary (name, relationship, %):
Trustee for Minor Beneficiaries*:
*Please note that a Trustee must be appointed for any beneficiary under the age of 18, or any benefit designated to them will be held until their 18th birthday.
____________________________________________
_________________________
Employee Signature
Date Signed (mm/dd/yyyy)