My members / Member documents/ Coverage statement

Plan member coverage statement

French version

Member information

John Smith

01 Jan 2012

52525252

26 Oct 1954

004

$0.00

A - Staff (Employee Levels 1 to 9)

Female

123 Pinebush Drive
Toronto, ON
M1P 2Q3

Coverage information

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
EE Life 21 Jul 2013 0011112 $60,000 $60,000 Active
Employee Life 01 Oct 2015 0011112 120,000.00 120,000.00 Active
Optional Life 01 Oct 2015 0011112 10,000.00 10,000.00 Active
Spousal OL 01 Oct 2015 0011112 10,000.00 10,000.00 Active
AD&D 01 Oct 2015 0011112 120,000.00 120,000.00 Active
Voluntary AD&D 01 Oct 2015 0011112 10,000.00 10,000.00 Active
Long Term Disability 01 Oct 2015 0011112 3,750.00 3,750.00 Active
Optional Critical Illness 01 Oct 2015 0011112 10,000.00 10,000.00 Active
Spousal Critical Illness 01 Oct 2015 0011112 10,000.00 10,000.00 Active
Child Critical Illness 01 Oct 2015 0011112 5,000.00 5,000.00 Active

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

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 benefit booklet or your plan administrator.

Date Prepared: 27 Jan 2014