Mechanical Contractors Association of Alberta

Group Benefit Enrolment Application

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Keeping Your Information Confidential

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Instructions

Section 1 is to be comleted by the plan adminstrator.
All remaining sections are to be completed by the plan member.
* Denote a required field

1Information to be completed by plan adminstrator

Contract Number :

Contractholder Name :

Application Type :

Date of Hire/Re-hire [YYYY/MMM/DD] :

Plan Memeber ID :

Class / Plan :

Effective Date of Coverage [YYYY/MMM/DD] :

Location / Billing Group Number :

Location / Billing Group Name :

Occupation :

Salary Amount :

Salary Type :

If you selected Hourly, please indicate how many hours per week.

Hours Per week :

If you selected Other, please specify.

Other :

2Plan member details

* Plans Member's Name [First, Middle Initial, last] :

* Gender :

* Address [Street number and name, apartment or suit :

* City :

* Province :

* postal code :

* Date of Birth [YYYY/MMM/DD] :

* Language :

* Province of Residence :

* Province of Employment :

* Marital Status :

* Coverage Selection :

3Refusal of benefits

If you or your dependants are presntly covered for Extended Health Care and/or Dental Care benefits inder another group contract you may refuse the be covered for such benefit(s) under this contract by selecting the applicable option for each benefit:

I refuse coverage for myself and my dependents und :

I refuse coverage for my dependents under :

4Spouse details

Complete this section only if you are applying for coverage for your spouse

Spouse's Name [First, Last] :

Gender :

Date of Birth [YYYY/MMM/DD] :

Is your spouse covered for Ectended Health Care and/or Dental benefits by his/her employr's plan

Spouse is Covered ? :

If Yes, please indicate spouse's coverage:

Dental Care :

Extended Health Care :

Name of Benefits Carrier :

5Children details

Complete this section only if you are applying for coverage for your children

IMPORTANT:

A spouse must first claim his/her own employer's plan.
Claims for covered children must be sent first to the plan of the parent whose birth date falls earlier in the year.

¹ A student is a child age 21 or over but under age 25, who is full–time student attending educational institution recognized by Canada Revenue Agency, as long as the child is not married or in any other formal union and is entirely dependent on you for financial support. (For Quebec PLan members please check with your plan adminstrator for dependent student age limit.)
² To enrol an overage disabled child, complete a Handicapped Child Coverage Form, and send it to us within 31 days of the date the dependent reaches the age limit.

1) Child's Name [First, Last] :

1) Date of Birth [YYYY/MM/DD] :

1) Child Gender :

1) Child is Student ¹ ? :

1) Overage Disabled Child ² ? :

2) Child's Name [First, Last] :

2) Date of Birth [YYYY/MM/DD] :

2) Child Gender :

2) Child is Student ¹ ? :

2) Overage Disabled Child ² ? :

3) Child's Name [First, Last] :

3) Date of Birth [YYYY/MM/DD] :

3) Child Gender :

3) Child is Student ¹ ? :

3) Overage Disabled Child ² ? :

6Beneficiary nomination

IMPORTANT:

Be sure to show the beneficiary's first and last name, as well as the relationship to you.

A revocable nomination can be changed at any time without the beneficiary's consent. You can not change an irrevocable beneficiary nomination unless certain requirements are met.

If you are nominating a beneficiary who is a minor, please see section 8 or 9.

1) Name [First, Last] :

1) Relationship to Plan Member :

1) Percentage :

2) Name [First, Last] :

2) Relationship to Plan Member :

2) Percentage :

3) Name [First, Last] :

3) Relationship to Plan Member :

3) Percentage :

In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you select Yes for the following option:

Revocable Beneficiary :

7Appointing contingent beneficiaries

1) Name [First, Last] :

1) Relationship to Plan Member :

1) Percentage :

2) Name [First, Last] :

2) Relationship to Plan Member :

2) Percentage :

3) Name [First, Last] :

3) Relationship to Plan Member :

3) Percentage :

In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary will be irrevocable unless you select Yes for the following option:

Revocale Beneficiary :

8Nomination of trustee for minor beneficiary other than Quebec redsidents

If you wish to designate minor children as beneficiaries, a trustee must be assigned

¹ A minor is a child who has not reached the age of majority as defined by provincial legislation.

Any payments becoming due while the beneficiary(s) are a minors¹, are to be made to the trustee name indicated below, or failing such trustee to the duly appointed guardian of such minor child as trustee. Payment to the trustee will discharge the company.

Trustee Name :

9Nomination of trustee/adminstrator for minor beneficiary for Quebec redsidents

In Quebec, If you wish to designate minor children as beneficiaries, an adminstrator may be designated.

A trustee may also be designated but a trust must then be set up more formally in accordance with the Civil Code of Quebec.

A lawyer or notary should then be consulted. Unless specifics of a trust are provided, an appointment of trustee/adminstrator herein shall refer to an adminstrator according to the Civil Code of Quebec.

¹ A minor is a child who has not reached the age of majority as defined by provincial legislation.

Any payments becoming due while the beneficiary is a minor¹, are to be made to the trustee/adminstrator name indicated below, or failing such trustee/adminstrator to the minor child's tutor. Payment to the trustee/adminstrator or to the minor child's tutor will discharge the company.

Trustee / Adminstrator Name :

10Authorization

I am authorized to disclose information about my spouse and dependents in order to enrol them in the plan
By enrollin in this plan, I authorize the following:

Sun Life Assurance Company of Canada, its agents and service providers, its reinsurers and their service providers to use and exchange relevent information about me to underwrite, adminster and adjudicate claims.
My plan sponsor, and its agents to use the information collected in this form for benefits adminstrations and to make any necessary payroll deductions which may be required.
Sun Life Assurance Company of Canada, its agents and service providers, and my plan sponsor and its agents to use and exchange information about me, my spouse and dependents necessary for enrolment ad for the purpose of continuing adminstration of the plan.

I declare that the information above is accurate and true.

A photocopy or electronic version of my authorization in this section 10 is as valid as the original.

Mechanical Contractors Association of Alaberta

Group Insurance & Medical Benefits Trust

* Name in full :

* Address :

* Postal Code :

* Social Insurance Number :

* Home phone number :

* Present Employer :

* Effective Date of Insurance [Day / Month / Year] :

* Date Employed [Day / Month / Year] :

* Occupation / Position :

* Salary [Monthly] :

* Date of Birth [Day / Month / Year] :

Date of Marriage [Day / Month / Year] :

Spouse's Name [First, Last] :

Date of Birth [Day / Month / Year] :

Spouse's Alberta health Care Number :

Beneficiary Full Name :

Beneficiary Relationship :

Dependents:

1) Name [First, Last] :

1) Date of Birth [Day / Month / Year] :

2) Name [First, Last] :

2) Date of Birth [Day / Month / Year] :

3) Name [First, Last] :

3) Date of Birth [Day / Month / Year] :

4) Name [First, Last] :

4) Date of Birth [Day / Month / Year] :

Dated 05 / 19 / 2012

Plan Member Name [name of the applicant] *:

Plumbing & Mechanical Contractors

Group Benefit Enrolment Application

Keeping Your Information Confidential

Instructions

Group Insurance & Medical Benefits Trust

Dependents:

Dated 05 / 19 / 2012