Group Benefits and Pension Update/Changes Update/Changes of Information To be completed and signed by the Employer or authorized Benefit Reps ER#(Required)Employer Name(Required)Effective date of change(Required) MM slash DD slash YYYY Employee ID number(Required)Canada Life member ID numberEmployee Name(Required) First Last Reason for Change(Required)Employment updatePersonal Information updateCoverage updateSalary updateLife insurance beneficiary updateDependent information updatePension contribution updateBenefit class updateUpdate working hours/days/weeksBenefit class and salary updateFor multiple selections, click from the selection + Ctrl to continue selecting more optionsNew legal name First Last New address Street Address City State / Province / Region ZIP / Postal Code New home phone numberNew Cell Phone numberNew personal Email Marital Status(Required) Single Married Other Employee's date of birth MM slash DD slash YYYY Employment status(Required) Employment Termination Employee Resignation Retirement Reinstate employment Disability leave Maternity leave Return to work Transfer of employment Unpaid leave of absence Retiring employee would like to:(Required) Keep extended health and dental coverage by join the retiree plan Terminate extended health and dental coverage Benefit Class Class 1 – Permanent F/T or P/T employee Class 2 – Short-term 1-year contract Class 3 – Approved leave of absence (except for Maternity Leave) Class 4 – Ordained priests Class 5 – Retiree member Class 8 – Non-salaried employee (religious order) Class 100 – Pension only (hours dropped below 20 hours/week or earning 35% of the YMPE) Pension contribution Suspend contribution while on leave Reinstate pension contribution at the eligible level Current Employer(Required)New Employer(Required)New annual gross salary(Required)No. of hours worked per day(Required)No. of days worked per week(Required)No. of weeks paid per year(Required)Pension contribution while on maternity leave Suspend contribution while on maternity leave Lower contribution level while on maternity leave Reinstate contribution at the eligible level Lower contribution level while on maternity leave to:(Required) 3% 7% 8% Reinstate benefits and pension Reinstate group benefits coverage Reinstate contribution at the eligible level Update Group Coverage(Required) Waive coverage Add coverage Reinstate coverage – Back to work from LOA Keeping benefits/no update Benefits while on maternity leave(Required) Keep all benefits Waive all benefits while on maternity leave Coverage update(Required) Add extended health coverage Add dental coverage Add Coverage as a Late Applicant Effective date of loss coverage through another plan or date of marriage(Required) MM slash DD slash YYYY Waive extended health coverage for(Required) myself and my dependent my dependents only (Single coverage) waive while on LOA (Class 3) Keep coverage while on LOA (Class 3) Keep current extended health coverage Waive dental coverage for(Required) myself and my dependent my dependents only (Single coverage) waive while on LOA (Class 3) Keep coverage while on LOA (Class 3) Keep current dental coverage Insurance Provider(Required)Policy number(Required)List ALL Primary Beneficiary(ies)Enter the beneficiary’s full name: First Name, Last Name, Relationship to the member and the share %List ALL Contingent Beneficiary(ies)Enter the beneficiary’s full name: First Name, Last Name, Relationship to the member and the share %Trustee for minor beneficiary or contingent beneficiaryEnter the trustee’s full name and contact informationUpdate Dependent(Required) Add dependent Remove dependent Update information Dependent information(Required)First Name, Last name, relationship, date of birth Multiple entries = point formAs per the effective date of change, the employee is entitled the matched level selected(Required) 3% 7% 8% 9% Voluntary RPP contribution amount:Voluntary TFSA contribution amount:Voluntary RRSP contribution amount:Authorization and Employer SignatureI, the employer/employer’s representative, certify that I obtained authorization from the above named employee, to apply/update the for coverage information 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 Representative's Email Address(Required) Employer/Employer Representative's Name(Required) First Last Employer/Employer Representative's Signature(Required)Upload signed intake form or supporting PDF documentMax. file size: 512 MB.Upload signed pension form or other supporting documentsMax. file size: 512 MB.UntitledFirst ChoiceSecond ChoiceThird Choice