Fillable Group Benefits Enrolment/Change Form (Ryerson Polytechnic University)

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Group Benefits Enrolment/Change Form (Ryerson Polytechnic University)

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The Group Benefits Enrolment/Change Form (Ryerson Polytechnic University) form is 2 pages long and contains:

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  • 2 check-boxes
  • 103 other fields

Country of origin: CANADA
File type: PDF

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Group Benefits Enrolment/Change Form
CONTRACT NUMBERS: Life - 50813 | AD&D - 50813 | LTD - 50580 | Health & Dental - 25180
Please fill out each required field electronically prior to printing. Once completed, please submit a signed copy to Ryerson HR Pensions
& Benefits. For detailed group Benefits information, visit the Human Resources website at ryerson.ca/hr/benefits.
Human Resources
1 - Employee details
New Employee
Change of Information
Effective Date of Change (YYYY-MM-DD)
Employee ID Number
Last Name Middle Initial First Name
Gender (M or F)
Do you have valid Provincial Health Insurance (e.g. OHIP)?
Yes No
If no, please contact HR, Pension & Benefits
Current Family Status:
Married
Single Common Law* Separated Civil Union
Widowed Divorced
* I hereby clarify that, as of this date of declaration, I have a common law spouse as defined in the Group Benefits Insurance contract and this person
has been publicly represented as my spouse for at least 12 consecutive months prior to the date of this declaration.
2 - Extended health care and dental benefits
You and your dependants must have provincial health insurance to enrol in the following. Please select the coverage:
Extended Health Care:
Single Family
Dental Care:
Single Family
3 - Spouse details
New Change No Change
Complete this section only if you are applying for coverage for your spouse. Spouse should be enrolled within 31 days of member's
initial enrolment or related life event (e.g. marriage).
Spouse's Last Name Spouse's First Name Date of Birth (YYYY-MM-DD) Gender
Is your spouse covered for Extended Heath and/or Dental Care benefits by their employer?
Yes No
If yes, please indicate:
Extended Health Care:
Single Family
Dental Care:
Single Family
Does your spouse have valid Provincial Health Insurance (e.g. OHIP)?
Yes No
If no, please contact HR, Pension & Benefits
Definition of a Spouse: Your spouse by marriage or under any other formal union recognized by law, or your partner of the opposite sex or of the same sex who is publicly
represented as your spouse, is an eligible dependent. You can only cover one spouse at a time.
Note: Canadian Life and Health Insurance Association Guidelines (CLHIA) state: a spouse must first claim from his/her own employer's plan. Please refer to the Human
Resources website at www.ryerson.ca/hr/employee-resources for Coordination of Benefits information.
4 - Dependant children details
New
Change No Change
Complete this section only if you are applying for coverage for your children. Dependant Children should be enrolled within 31 days of
member's initial enrolment or related life event (e.g., marriage, birth of a child, adoption etc.)
Child's Last Name Child's First Name
Birth Date
(YYYY/MM/DD)
Gender
(M or F)
Student*
(Yes/No)
Over-age Child
with Disability**
(Yes/No)
OHIP***
(Yes/No)
Definition of dependant child: unmarried children (including stepchildren, legally adopted children and children of a common-law spouse during the time that coverage for
the spouse is in effect), who are under 21 years of age and depend on you for support; who are under 25 years of age, depend on you for support and attending an
institution of higher learning as a full-time student; or any age and are permanently mentally or physically disabled and incapable of self-support with uninterrupted coverage
under the Ryerson plan prior to disability. Please contact Sun Life for more information about coverage for a disabled dependant.
* You must provide confirmation of enrolment in full-time studies, at an educational institution recognized by the Canada Revenue Agency, to Human Resources,
Pension & Benefit Unit within a week of enrolment and the start of each academic year thereafter.
** To enrol an over-age child with a disability, complete a disabled child coverage form and send to Sun Life within 31 days of the date the child reaches the age limit.
*** If no, please contact Human Resources, Pension & Benefit.
Note: Canadian Life and Health Insurance Association Guidelines (CLHIA) state:Covered dependant children must first claim from the plan covering the parent
with the earlier date of birth in the calendar year.
5 - Voluntary accident insurance (Employee Paid)
Type of Plan:
Single Only Family Plan
I do not wish to purchase coverage
Benefit Amount Selected (Max Coverage $500,000 (Units of $10,000)
6A - Beneficiary information
New Change No Change
Beneficiary for Life Insurance (including Supplemental Life), Business Travel Accident and Voluntary Accident Insurance (if applicable).
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
MUST EQUAL 100%
If you are nominating a beneficiary who is a minor (under age 18), you must complete SECTION 6C. According to legal requirements, Sun Life Assurance
Company of Canada cannot pay benefits to beneficiaries who are minors, a TRUSTEE must be designated. If you do not nominate a beneficiary, the proceeds will
be paid to your estate and therefore may be subject to estate taxes and creditors. In Quebec, if you name your legal spouse (married or civil union) as the
beneficiary, this beneficiary will be irrevocable unless you check the revocable box. A revocable nomination can be changed at any time without the beneficiary's
consent. Your cannot change an irrevocable beneficiary nomination unless certain requirements are met.
Revocable Beneficiary
6B - Appointing contingent beneficiaries
New Change No Change
If there are no surviving beneficiaries at the time of my death, I declare that the following contingent beneficiaries shall receive the
proceeds. If there are no surviving contingent beneficiaries at the time of my death, the proceeds shall be paid to my estate. Unless I
specify otherwise, my contingent beneficiaries will apply to all my benefits.
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
Last Name First Name Relationship to Employee Percentage %
MUST EQUAL 100%
In Quebec, if you name your legal spouse (married or civil union) as the beneficiary, this beneficiary
will be irrevocable unless you check the revocable box:
Revocable Beneficiary
6C - Nomination of trustee for minor beneficiary
If you wish to designate minor children (under the age of 18) as beneficiaries, a trustee must be designated. Any payments becoming
due while the beneficiary(ies) is a minor are to be made payable to
as trustee, or failing
such trustee to the duly appointed guardian of such minor child as trustee. Payment to the trustee will discharge Sun Life Assurance
Company of Canada. Details for Quebec residents will differ, please contact Human Resources.
Note: In Quebec, any amount payable to a minor beneficiary during his/her minority will be paid to the parent(s) or legal guardian on his/her behalf.
7 - Signature for beneficiary designation and privacy authorization
Please read this section carefully
You must be authorized to disclose information about your spouse and dependants in order to enrol them in the Plan.
By enrolling in this Plan, I authorize the following:
1. This signature for beneficiary designation below reflects my genuine wishes for nominating a beneficiary for Life Insurance (including
Supplemental Life), Business Travel Accident and Voluntary Accident Insurance (if applicable).
2. Sun Life Assurance Company of Canada, their agents and service providers to use and exchange information collected in this form to
underwrite, administer, adjudicate claims, and deposit claim payments.
3. My Plan Sponsor, Ryerson University, to use the information collected in this form for benefits administration, to disclose my salary
information and my Ryerson e-mail address to Sun Life Assurance Company of Canada and their agents and service providers for benefit
administration and to make any necessary payroll deductions which may be required for benefit administration.
I declare that the information above is accurate and true. Inaccurate information may invalidate my claim.
Please print this document and sign
A photocopy or electronic version of this signature is not valid for recording beneficiary nominations.
Employee Signature
Date
Location: 1 Dundas St. W. 16
th
floor Mail: 350 Victoria Street, Toronto, Ontario, Canada M5B 2K3
Tel: 416-979-5075 Fax: 416-979-5163 hr@ryerson.ca www.ryerson.ca/hr
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Group Benefits EnrolmentChange Form (Ryerson Polytechnic University)

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Completed 20 October 2020

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