2 Plan member information

You can obtain your plan contract number, division number and your plan member certificate number from your benefit card.

Plan sponsor name

Plan contract number

Division

Certificate number

Last Name

First Name

Mr. Mrs. Ms.

Is the benefit taxable?

Yes No

Date of birth


						1
2	3	4	5	6	7	8
9	10	11	12	13	14	15
16	17	18	19	20	21	22
23	24	25	26	27	28	29
30

Sex

Height

Weight

Are you responsible for any dependents?

Yes No

Language Preference:

English French

Street address (number, street, apt)

City

Province

Postal code

Primary phone number

Alternate phone number

Work phone number

Extension

By providing my personal e-mail address, I am authorizing Manulife to use the address provided as an additional means of communication about my file. I acknowledge that correspondence by e-mail may contain personal information including, but not limited to medical, employment and financial information. I understand that my personal information is being sent in a manner that is not yet guaranteed as a secure means of communication.

E-mail address