Fillable POSTDOCTORAL ASSOCIATES BENEFIT APPLICATION/ CHANGE FORM (Brescia University College)

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POSTDOCTORAL ASSOCIATES BENEFIT APPLICATION/ CHANGE FORM (Brescia University College)

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The POSTDOCTORAL ASSOCIATES BENEFIT APPLICATION/ CHANGE FORM (Brescia University College) form is 2 pages long and contains:

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  • 23 check-boxes
  • 122 other fields

Country of origin: CANADA
File type: PDF

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SECTION 1: PERSONAL INFORMATION
Employee Last Name:
Employee ID #:
Employee First Name: UWO Extension:
SECTION 2: EXTENDED HEALTH AND DENTAL PLANS—CHOOSE ONE
Employee—Employer Paid
Family—Required monthly contribution from member. Current monthly cost is $170.75
Spouse and/or child(ren) eligible to be covered under the Family Extended Health & Dental plans
Add
First Name
Last Name
Relationship
Date of Birth
YYYY/MM/DD
Student/Disabled
For any overage dependent child(ren), please indicate whether student or disabled. A completed Overage Dependent Child Declaration Form is required for coverage to be
activated. Coverage for a disabled child is subject to the approval of our carrier. Both forms are available upon request.
SECTION 3: OPTIONAL LIFE—CHOOSE ONE
I elect the following coverage:
Optional Life Insurance Coverage in the amount of $_________________
Waive Participation
Optional Life Insurance Primary Beneficiary Designation
First Name Last Name
Date of Birth
YYYY/MM/DD
Relationship
Percentage
Designated
Total must equal 100%
I hereby revoke any previous beneficiary designations in relation to my forgoing coverage(s) and designate the person(s) named above.
Optional Life Insurance Contingent Beneficiary Designation
First Name Last Name
Date of Birth
YYYY/MM/DD
Relationship
Percentage
Designated
Total must equal 100%
Contingent Beneficiary(ies) Designation in the event that the named Primary beneficiary(ies) predecease me or whose death occurs simultaneous to mine, I hereby designate
the above contingent beneficiary(ies).
SECTION 4: DEPENDENT LIFE INSURANCE—CHOOSE ONE
Elect coverage
Waive Participation
Spouse and/or child(ren) eligible to be covered under the Dependent Life Insurance Plan
Add
Remove
First Name
Last Name
Gender
Relationship
Date of Birth
YYYY/MM/DD
Student/
Disabled
For any overage dependent child(ren), please indicate whether student or disabled. Proof of overage dependent status is needed prior to dependent having active coverage.
POSTDOCTORAL ASSOCIATES
BENEFIT APPLICATION/ CHANGE FORM
Send completed forms to hrhelp@uwo.ca or
Human Resources, Support Services Building, Room 4159, London, ON, N6A 3K7
Monthly Cost for Optional Life Insurance
(based upon each $50,000 of coverage & non-smoker rates)
24-34
35-39
40-44
45-49
50-54
55-59
60-65
Male
$1.30
$1.50
$2.30
$3.45
$6.55
$11.00
$16.20
Female
$0.95
$1.30
$1.50
$2.45
$4.15
$6.55
$10.70
Current Premium Cost: $8.79/month
Life Insurance coverage of $40,000 on your spouse and $10,000 on each eligible child.
You may purch
ase any amount of insurance in multiples of $50,000 subject to
a
minimum of $50,000 and a maximum of $500,000.
Enrolment fo
rms received prior to February 19, 2021 will not require
proof of good
health for coverage up to $150,000. Amounts greater than
$150,000 will r
equire proof of good health. Human Resources will issue the
necessary pape
rwork for coverage requests greater than $150,000. Previous
elections greater than $150,000 will not require proof of good health.
Have you smoked (cigarettes, cigars, pipe, etc) or used
tobacco in any form within the last 12 months?
Yes No
0
0
Resources:
uwo.ca/hr/PDA
SECTION 5: VOLUNTARY PERSONAL ACCIDENT INSURANCE—CHOOSE ONE
Employee Only coverage in the amount of $_______________
Family coverage in the amount of $_______________
Waive Participation
Spouse and/or child(ren) eligible to be covered under the Voluntary Personal Accident Insurance Plan
Add
Remove
First Name
Last Name
Gender
Relationship
Date of Birth
YYYY/MM/DD
Student/
Disabled
For any overage dependent child(ren), please indicate whether student or disabled. Proof of overage dependent status is needed prior to dependent having active coverage.
Voluntary Personal Accident Insurance-Family Coverage Primary Beneficiary Designation
First Name Last Name
Date of Birth
YYYY/MM/DD
Relationship
Percentage
Designated
Total must equal 100%
Voluntary Personal Accident Insurance-Family Coverage Contingent Beneficiary Designation
First Name Last Name
Date of Birth
YYYY/MM/DD
Relationship
Percentage
Designated
Total must equal 100%
Contingent Beneficiary(ies) Designation in the event that the named Primary beneficiary(ies) predecease me or whose death occurs simultaneous to mine, I hereby designate the
above contingent beneficiary(ies).
SECTION 6: TRUSTEE DESIGNATION FOR LIFE PLANS IF NAMED BENEFICIARY IS UNDER THE AGE OF 18
Life Insurance Plan First Name Last Name Relationship
Optional Life Insurance
Voluntary Personal Accident Insurance
SECTION 7: AUTHORIZATION
I hereby apply for the above benefit plans and authorize the deduction from my pay for the amounts required towards the costs of the
benefits for which I am now, or may later become, eligible. I understand that I may be asked to provide proof of eligibility for all
dependents listed at a later date. I hereby revoke any previous beneficiary designations in relation to my forgoing coverage(s) and
designate the person(s) named below.
______________________________________________________________ ______________________________________________
Signature of Employee Date
For further information on your Group Benefit plans and premium rates, please refer to our website at http://www.uwo.ca/hr. The personal
information provided on this form is protected under the provisions of the Privacy Act and will be used only for the purposes for which it
was collected.
You may purchase any amount of insurance in multiples of $10,000 subject to a minimum
of $20,000 and a maximum of $500,000.
Current Premium Cost:
Employee only: $1.50/month per $100,000 of coverage
Family: $2.40/month per $100,000 of coverage
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POSTDOCTORAL ASSOCIATES BENEFIT APPLICATION CHANGE FORM (Brescia University College)

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Completed 5 February 2021

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