New Employee Benefits and Pension Application Employer Name(Required)Benefits Employer Number (ER#)(Required)Refer to your monthly billing invoice for the Employer Number.Original Hire Date(Required) MM slash DD slash YYYY Coverage Effective Date(Required) MM slash DD slash YYYY Intention to Rehire the Employee(Required) Yes, the employer will rehire the employee No, the employer does not intend to rehire the employee Employee's Job Title(Required)Benefits Class Class 1: Permanent Full-time/Part-time Employee Class 2: One-Year Employee Class 4: Ordained Priests Class 8: Non-salaried Employees Class 100: Pension Only Employee's annual gross salary(Required)Employee's gross salary for the month(Required)If the employee starts mid-month, please provide the gross earnings from the date hire to the end of the month.Number of hours work per week(Required)Please enter a number from 20 to 48.Number of days work per week(Required)Please enter a number from 2 to 7.Number of weeks paid/worked per year (including paid vacation)(Required) 43 45 48 52 Employee InformationEmployee's Legal Name(Required) First Middle Last Employee's marital status(Required) Single Married Other Employee's gender(Required) Male Female Employee's Date of Birth(Required) MM slash DD slash YYYY Employee's Religious Affiliate(Required) Catholic Non-Catholic Other Employee's Complete Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Employee's Email(Required) Cell Phone Number(Required)CoverageHealthcare Coverage(Required) Single Coverage Single Coverage – waive Dependent(s) (DEPENDENT(S) MUST BE COVERED ELSEWHERE) Family Coverage Waive Coverage – MUST BE COVERED ELSEWHERE Healthcare Provider(Required)Healthcare Policy Number(Required)Dental Coverage(Required) Single Coverage Single Coverage – waive Dependent(s) (DEPENDENT(S) MUST BE COVERED ELSEWHERE) Family Coverage Waive Coverage – MUST BE COVERED ELSEWHERE Dental Coverage Provider(Required)Dental Coverage Policy Number(Required)Is the employee joining the Matched Pension Plan?(Required) Yes, the employee would like to join the employer-matched pension plan – MUST COMPLETE THE PENSION APPLICATION FORM No, the employee do not want to join the employer-matched pension plan The employer is not part of the Archdiocese Pension Plan What is the contribution percentage?(Required) 3% of the annual gross earnings 7% of the annual gross earnings Higher tier level (if applicable) – additional paperwork required and subject to approval Employer's ConsentAuthorizations and DeclarationsYour Name(Required) First Last I, the employer/employer’s representative, certify that I obtained authorization from the above named employee, to apply for coverage under the group benefits plan issued by Canada Life.(Required) I certify on behalf of the employee that I provided the employee with the Authorization and Declaration clause stated below.I, the above mentioned employee applying for the RCAV group benefits and/or pension coverage authorized: • My employer to deduct from my pay and remit to Canada Life the plan member contributions required under the plan, if applicable; • Canada Life to use my social insurance number for tax reporting purposes where it is required in the administration of the plan; • Canada Life, any healthcare provider, my Benefit Representative at the local level, the Benefits Administration office, other insurance or reinsurance companies, administrators of government benefits or other benefits programs, other organizations, or service providers working with Canada Life to exchange personal information, when necessary to determine my eligibility for coverage, and to administer the plan. I agree that a photocopy or electronic copy of this Authorizations and Declarations section is as valid as the original. I certify that the information given is accurate, correct and complete to the best of my knowledge. Employer/Employer's Representative Email(Required) Employer/Employer's Representative's Signature(Required)