New Employee Benefits and Pension Application Benefits Employer Number (ER#)(Required)Refer to your monthly billing invoice for the ER#.EMPLOYER PARISH/SCHOOL NAME(Required)Original Hire Date(Required) MM slash DD slash YYYY Coverage Effective Date(Required) MM slash DD slash YYYY Employee's Job Title(Required)Intention to Rehire the Employee(Required) Yes, the employer will rehire the employee No, the employer does not intend to rehire the employee 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)Number of hours work per week(Required)Please enter a number less than or equal 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 (use CAPITAL LETTERS) 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 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Employee's Email(Required) Personal email preferredCell 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)Spouse /Dependent informationFirst NameLast NameDate of BirthGenderRelationship Add RemovePlease confirm if the employer has received and kept in file the original completed and signed Beneficiary Designation form from the employee.(Required) I confirm Upload the completed and signed Beneficiary Designation form:(Required)Max. file size: 512 MB. Is the employee joining the Matched Pension Plan?(Required) Yes, the employee would like to join the employer-matched pension plan – MUST UPLOAD THE COMPLETED 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 pension contribution level as % of the annual gross earnings?(Required)Please enter a number from 1 to 9.Upload the SIGNED pension application form to proceed(Required)Max. file size: 512 MB. Upload the completed and signed In-take form:(Required)Max. file size: 512 MB. 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 the employee has read and understand and agree with the contents of Canada Life’s Privacy clause stated below.Protecting your personal information. At Canada Life, we’re committed to protecting personal information and respecting your privacy. Personal information is information that either on its own or combined with other information allows an individual to be identified. This includes your name and address, as well as more sensitive information such as your health and financial records. When applicable, this includes information about other people such as your spouse, common-law partner, and children. How we use your personal information. Your personal information is used to provide you with products and services and to improve our business operations. This includes verifying your identity, maintaining your profile, and informing you about features of the products you already have with us. It’s also used to provide you with advice, evaluate your eligibility for products, price our products, collect feedback on our customer service, process claims and other financial transactions, protect you and us from risks such as cyber threats and fraud, and comply with legal obligations. If you provided your social insurance number (SIN), we’ll use it for tax reporting. Your SIN is also used to link your products together and to keep your information separate from other customers with similar names. Who we share personal information with. We share your personal information with other people and organizations who help us administer your products and provide you with services. This may include your advisor or people who work with your advisor, our Canadian subsidiaries, and other organizations that provide us services such as paramedical examiners, medical laboratories, MIB, LLC., specialty coverage providers, independent medical examiners, and pharmacy benefits managers. As well, we may share your information with claims assessors, travel assistance providers, technology suppliers, other insurance or reinsurance companies, other financial institutions, and credit reporting agencies. As part of our day-to-day business, your personal information may be communicated to government departments and agencies, and may be communicated outside your province of residence or outside Canada. We take protecting your personal information seriously and we’ll never sell your personal information to anyone. You’re in control of your personal information. We respect your privacy preferences and follow them when using your personal information. At any point in your relationship with us, you can choose how your personal information is used by updating your privacy preferences through your online account or by submitting a request through our privacy centre at canadalife.com/privacy. This includes choosing whether you receive customer experience surveys, the use of your SIN for non-tax reporting purposes, and whether and how you want to receive information and offers from Canada Life using the personal information we collect from you throughout your relationship with us. You can also exercise other privacy rights through our privacy centre such as access to or correction of your personal information. If you choose to remove your consent to the collection, use and disclosure of the personal information required to serve you and meet our legal obligations, we may not be able to continue to provide you with products and services. Want to learn more? Please visit canadalife.com/privacy. 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 plan sponsor / 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 and as an identification number where it is required in the administration of the plan; • Canada Life, any healthcare provider, my plan administrator (including Benefit Representative at the local level and 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 or the above to exchange personal information, when relevant and necessary to determine my eligibility for coverage and to administer the plan. If applying coverage for my spouse and/or dependents, I confirm that I am authorized to act on their behalf. I agree that a photocopy or electronic copy of the Authorizations and Declarations section is as valid as the original. I certify that the information given is true, correct and complete to the best of my knowledge. Employer/Employer's Representative Email(Required) Employer/Employer's Representative's Signature(Required)