My members / Member documents/ Coverage statement

Plan member coverage statement

Member information

Name

ABC COMPANY

Effective date

01 Jan 2012

Member certificate

57083

Date of birth

26 Oct 1954

Division

001

Salary

$0.00

Plan

A - Staff (Employee Levels 1 to 9)

Gender

Female

Mailing address

90 ANGUS DR,
TORONTO, ON
M2J 2X1

Benefit	Original Benefit Effective Date	Plan Contract	Requested Coverage	Approved Coverage	Status
EHC	01 Jan 2012	0011112	Family	Family	Active
Dental	01 Jan 2012	0011112	Family	Family	Active

Name	Birth Date	Relationship	Gender	Health Coverage	Dental Coverage
MONICA ABADIR	13 Jun 1993	Child	Female	Covered	Covered
RAAFAT ABADIR	26 Nov 1953	Spouse	Male	Covered	Covered

Benefit amounts subject to approval are not effective until approved by Manulife. The benefit will take effect on the effective date shown, which reflects any applicable waiting periods.
Benefits not subject to approval are effective on the date shown. This date reflects any applicable waiting period.

For details on waiting periods see your benefit booklet or your plan administrator.

Date Prepared: 27 Jan 2014