2 Plan sponsor information

Plan contract number

Plan sponsor name

Street address (number, street, suite)

City

Province

Postal Code

Plan sponsor contact last name

Plan sponsor contact first name

Job title

Phone number

Fax

Email address

Health centre contact and return to work contact

If different from above, please indicate the person in the health centre involved in disability absences.

Yes No

If different from above, please indicate the person we should contact to facilitate a return to work once this employee’s abilities and limitations are known.

Yes No