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Plan member coverage summary

Member information

John Smith

01 Jan 2012

52525252

24 Mar 1976

004

$60,000.00

A - Staff (Employee Levels 1 to 9)

Male

123 Pinebush Drive
Toronto, ON
M1P 2Q3

Coverage information

Benefit Original benefit effective date Plan contract Requested coverage Approved coverage Status Options Monthly premium
Employee Life 01 Oct 2015 0011112 98,000.00 98,000.00 Active 2 X Earnings 22.44
AD&D 01 Oct 2015 0011112 98,000.00 98,000.00 Active 2 X Earnings 2.16
EHC 01 Oct 2015 0011112 Single Single Active Health B 31.20
Dental 01 Jan 2012 0011112 Single Single Active Dental C 26.19
Long Term Disability 01 Oct 2015 0011112 3,039.00 3,039.00 Active 75% of Earnings w. COLA 86.61
Total:168.60

Dependant information

Name Birth Date Relationship Gender Health Coverage Dental Coverage
Jane Smith 17 Dec 1977 Spouse Female Covered Covered
Marie Smith 02 Feb 1998 Child Female Covered Covered
Chris Smith 01 Jan 1993 Over-age Student Male Not Covered Not Covered

Coverage history

  Name Birth Date Relationship Health COB Dental COB Status  
John Smith 01 Nov 1970 Self None None Active
Jane Smith 01 Nov 1972 Spouse Secondary Secondary Active
Marie Smith 02 Feb 1998 Child Primary Primary Active
Chris Smith 01 Jan 1993 Over-age Student Primary Primary Terminated

Up to three years of coverage history is available for each person listed above.

Note

  • 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 benefits booklet or your plan administrator.