CHANGE FORM
Existing Identication Number
Existing Policy and Section Number
Last Name
Instructions:
1) Earnings information is only required if life and/or income replacement benets apply.
2) Employer to forward original and keep second copy.
3) The Optional Group Life Insurance Statement of Health form must be completed when an ADD or CHANGE is requested for
Optional Life benets. The actual amount of coverage must be stated (not the amount of the increase / decrease).
TYPE OF CHANGE - CHECK ( 3)
q Address q Marital Status q Beneciary q Left Employ q Cancel Benets: Reason
q Dependent(s) q Retired q Telephone No. q Salary q Add Benets: Reason
q Benets q Deceased q Occupation q Transfer q Other:
CHANGE OF BENEFICIARY - In accordance with the terms and conditions of the Group Life Contract between the employer indicated below and Blue Cross Life Insurance Company
of Canada, I revoke all previous appointments of beneciary and hereby appoint the following as beneciary entitled to receive the proceeds arising by reason of my death.
Beneciary Last Name First Name Initial Relationship Percentage
1.
2.
3.
DD MM YY Policy Number Identication Number Last Name
MARITAL CHANGE - When an employee requests a change from single to family coverage within 31 days of marriage, family coverage will become effective as outlined in the
Medavie Blue Cross group benets contract. If later than 31 days, a statement of health may be required.
Date of change in marital status: If spouse has Medavie Blue Cross benets please complete:
AUTHORIZATION OF CHANGE -
I
certify that the information above is accurate and authorize payroll deductions, if required. I authorize Blue Cross to collect, use and disclose my
personal information as described in the Privacy Statement on the reverse of this form.
Employee Signature Witness Signature Date
TO BE COMPLETED BY EMPLOYER
Name of Employer Policy and Section Number Class of Coverage - Health Employee Class - Life and/ Occupation
and/or Dental or Disability Income
DD MM YY
(1)
(2)
Effective Date of Change Complete for Life and Disability Hours Payroll No. Completed for Employer by
Income Benets Worked Per (maximum 9 positions)
Earnings Per Week
Hour Month
Week Year $ Signature Date
BLUE CROSS LIFE INSURANCE COMPANY OF CANADA UNDERWRITES ALL LIFE AND DISABILITY INCOME BENEFITS.
COMPLETE ONLY AREAS AFFECTED BY THE CHANGE AND SIGN
Employee Last Name
Address (Street & No.)
City or Town
Province Telephone No.
( )
Postal Code Language Preferred
q English q French
A-Add
C-Change
D-Delete
Dependent
Status
BIRTH DATE
SEX
M/F
DD MM YY
FIRST NAME INITIAL
Employee
Spouse
Children
E- Student
(College/
University)
S-Disabled
OPTIONAL COVERAGES q ADD q CHANGE q DELETE
q Life q Long Term Disability q Dependent Life
q Health q AD & D q Weekly Indemnity
q Dental q Critical Conditions
Dependent life is automatically included if you indicate family status and eligible dependents.
STATUS
CHANGE
Life (state total amt.) Employee $ Spouse $
AD&D (state total amt.) q Single q Family $
Dependent Child Life q YES q NO
FORM-048(E) 07/10
BASIC COVERAGE q ADD q CHANGE q DELETE
q Single
q Family
* IF APPLICANT AND SPOUSE ARE NOT LEGALLY MARRIED, PLEASE PROVIDE
COMMENCEMENT DATE OF CO-HABITATION
COORDINATION OF BENEFITS
Do you or any of your dependents have other coverage under any other Insurer? q Yes q No If Yes, complete the following:
Name of the Other Insurer: Effective Date of Coverage:
Identication Number/Certicate Number: Policy Number:
Is the Coordination of Benets Single Coverage or Family Coverage? Please indicate under "Type of Coverage" S for Single or F for Family for the applicable benets.
Type of Coverage: All Hospital Extended Health Benets Vision Drugs Dental
Surname (if
different from
applicant )*
THIS AREA MUST BE COMPLETED FOR CHANGES TO BE PROCESSED
For designated beneciaries under the age of 18: I appoint as Trustee to receive any amount due for any beneciary
considered a minor under the Provincial jurisdiction of residence.
644 MAIN ST PO BOX 220 MONCTON NB E1C 8L3
230 BROWNLOW AVE DARTMOUTH PO BOX 2200 HALIFAX NS B3J 3C6
FOR ALL INQUIRIES: TEL 1-800-667-4511 FAX 506-869-9653
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
PRIVACY STATEMENT
I understand that the personal information provided herein, as well as
any other personal information currently held or collected in the future
by Medavie Blue Cross and/or Blue Cross Life Insurance Company of
Canada, may be collected, used, or disclosed to administer the terms
of my policy or the group policy of which I am an eligible member, to
recommend suitable products and services to me, and to manage
Blue Cross’s business. Depending on the type of coverage I carry,
limited personal information may be collected from and/or released to a
third party. These third parties include other Blue Cross organizations,
health care professionals or institutions, life and health insurers,
government and regulatory authorities, and other third parties when
required to administer and manage the benets outlined in the policy
of which I am an eligible member.
I understand that my personal information will be kept condential
and secure. I understand that I may revoke my consent at any time,
however, in some instances doing so may prevent Blue Cross from
providing me with the requested coverage or benets. I understand
why my personal information is needed and I am aware of the risks
and benets of consenting or refusing to consent to its disclosure.
A photocopy of this authorization shall be as valid as the original.
This consent complies with federal and provincial privacy laws. For
additional information regarding privacy policies at Medavie Blue Cross,
visit www.medavie.bluecross.ca or call 1-800-667-4511.
TM
The Blue Cross symbol and name are registered trademarks of the Canadian Association of Blue Cross Plans, used under licence by Medavie Blue Cross, an independent licensee of the Canadian Association of Blue Cross Plans.
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome