DECLARATION OF DEPENDENT CHILDREN AGED 18 TO 25
OR 21 TO 25 INCLUSIVE (ACCORDING TO CONTRACT PROVISIONS)
WHO ARE FULL-TIME STUDENTS
Denion of dependent child for the purposes of the Insurance Plan:
"Dependent child" means an eligible person who is a resident of Canada and who:
• is under 18 or 21 years of age (according to contract provisions) and over whom the member or the member's spouse exercises parental
authority unl he reached the age of majority;
• does not have a spouse, is 25 years old or under and is a full-me student at an accredited educaonal instuon and over whom the
member or the member's spouse would exercise parental authority if he were a minor.
Please return to: Desjardins Insurance, C. P. 3950, Lévis (Québec) G6V 8C6
19131A (2020-02)
Declaraon for the session, starng in
Member's last name and rst name:
Policy or group or contract number:
Cercate number:
Name of group or policyholder
or employer:
YYYY MM DD
YYYY MM DD
YYYY MM DD
Yes No
From
To
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Yes No
From
To
Yes No
From
To
Last name
First name
Date of birth
Name and address of educaonal
instuon aended
Full-me student
Signature of member Date
This form must be returned to Desjardins Financial Security Life Assurance Company, hereinaer Desjardins Insurance, in the month preceding
the beginning of each session.
Desjardins Insurance life health rerement logo
Address C. P. 3950 Lévis Québec G 6 V 9 X 8 web site desjardins life insurance dot com slash plan member Telephone 1 8 0 0 2 6 3 1 8 1 0
