Service Purchase Application Form Page 3
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4Form 160
Proof of previous earnings and service
PA R T B : O M E R S E M P L O Y E R O R P U B L I C
S E C T O R E M P L O Y E R / P E N S I O N P L A N
This form is for an OMERS Pension Plan member to apply for a cost to
employee’s records no longer exist), please advise the OMERS
purchase past service with a current OMERS employer, a former OMERS
member. You will be asked to provide a written statement
employer, or OMERS-associated employer, or a former public sector
confirming this.
employer/pension plan.
Personal information is collected for pension administration purposes by
Instructions for the former employer/pension plan
OMERS under the authority of Section 35 of the OMERS ct, 2006.
Please provide all of the relevant information for this OMERS
OMERS does not share a member’s personal information with any other
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member (former employee) as requested on this form.
person other than for purposes of pension plan administration, and, by
If there is more than one service period for this employee, please
providing personal information, the member consents to its use for those
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make extra copies of this form as needed.
purposes. The collection, use, retention and destruction of personal
Once you have completed and signed this form, return it directly to
information are subject to our Privacy Policy at
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the OMERS member.
Any questions regarding the collection of personal information should
If you are unable to complete this form (if, for example, the former
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be directed to OMERS Client Services at 1-800-387-0813.
Section 1 is to be completed by the OMERS member
1. MEMBER INFORMATION
Social insurance number/former employee ID number
OMERS membership number
Birthdate (m/d/y)
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Last name
First name
Middle name
Mr.
Mrs.
Ms.
Other:
Address (street number and name)
City
Province
Postal code
ON
I hereby authorize my former employer or my previous pension plan
Member’s signature
Date (m/d/y)
to release to OMERS any information on this form necessary to verify
my earnings and service, including my social insurance number.
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Sections 2, 3 and 4 are to be completed by the former employer/pension plan
2. PREVIOUS EMPLOYMENT INFORMATION
OMERS group number (if applicable)
Employer name
Date service began (m/d/y)
Date service ended (m/d/y)
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Costs for one service period can be requested in this section. For more than one period, photocopy this section as needed. Be sure to put the
OMERS membership number at the top of each page.
Service period
Are there any breaks in service or unpurchased leave periods within this time period?
Yes
No
If yes, please indicate the dates and the type of leave(s):
Date leave started (m/d/y)
Date leave ended (m/d/y)
Authorized leave/legal strike
Pregnancy/parental leave
Layoff/suspension*
Other**
______________________________
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Date leave started (m/d/y)
Date leave ended (m/d/y)
Authorized leave/legal strike
Pregnancy/parental leave
Layoff/ suspension*
Other**
______________________________
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*Periods of layoff/suspension cannot be purchased. **Other eligible types of leave: Emergency leave (as of Sep. 4/01); Family/Medical leave
(as of June 29/04); Reservist leave (as of Dec. 3/07); Organ donor leave (as of June 26/09).
Employment status during period
1.
Continuous full-time
2.
Non-full-time
% of full-time hours, excluding any period each year that the employee didn’t work.
Example: if full-time hours were 37.5 hours
%
per week, and the employee regularly worked 30 hours per week, the percentage of full-time hours worked would be 80% (or 30 ÷ 37.5 = 0.80).
Period each year the employee didn’t work (generally
From (m/d)
To (m/d)
applies to school boards or seasonal employees)
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3.
If the employee worked varying hours every year, provide the months of service worked each year
Year
Months
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