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3 Plan member identification and work information

Plan member last name

Plan member first name

Date of birth


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Certificate number

Primary phone number

Alternate phone number

Class

Division

Job title

Permanent employee

Yes No

Date of Hire


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Date for which the plan member was first covered under this plan.


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Has there been any interruption in the plan member’s coverage?

Yes No

Please indicate the HOURS of work in a normal week.

Is this shift work? Yes No

If yes, please provide work schedule or attach a copy of the work schedule.

Hours of work each day

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

If available, please provide a copy of a the work schedule.

File upload tips:

Supported format: pdf, tif, tiff, jpg, jpeg, jpe, jfif, gif, png
Maximum size: 5MB

Provide details if plan member's shift schedule is varied or rotational:

Is the member required to work night shift?

Yes No

Plan member’s gross salary as of the last date of work

Frequency of salary payments

Per week Per month

Was the plan member:

Salaried Hourly

What was the last date at work?


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Was this a full day/shift?

Yes No

Is the absence work related?

Yes No

What was the employee's first missed day of work?


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Has the employee returned to work?

Yes No

When?


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Did the employee return to:

Regular duties Modified duties

Tax Information

Is benefit taxable? Yes No

TD1 code

TP1 code

Plan member's province of residence for income tax purposes

Is employment income tax exempt according to terms of Indian Act and Income Tax Act? Yes No

Please indicate if any of the following have been paid (or are payable) since date plan member last worked

Salary continuance Yes No

Amount

From


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Vacation Yes No

Amount

From


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Sick leave Yes No

Amount

From


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Severance Yes No

Amount

From


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Employment insurance benefits Yes No

Amount

From


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Other Yes No

Source (E.g. Short-term disability benefits, commissions or bonuses, retirement pension.)

Amount

From