GROUP BENEFITS

ENROLMENT FORM
DEFINED

The Group Benefits Enrolment form is used by Group Administrators to advise Medavie Blue
GROUP BENEFITS ENROLMENT FORM
Cross of the addition of a new employee to their group benefit plan. It should be completed and
forwarded to Medavie Blue Cross as soon as the addition is known. This will keep records up-to- 644 MAIN ST PO BOX 220
MONCTON NB E1C 8L3
230 BROWNLOW AVE DARTMOUTH
PO BOX 2200 HALIFAX NS B3J 3C6
PO BOX 2000, 185 THE WEST MALL SUITE 1200
ETOBICOKE ON M9C 5P1
1981 MCGILL COLLEGE AVENUE, SUITE 100
MONTREAL, QC H3A 3A7
TEL: 1-800-667-4511 FAX: 1-506-869-9653 TEL: 1-800-667-4511 FAX: 1-506-869-9653 TEL: 1-800-355-9133 FAX: 1-506-869-9653 TEL: 1-888-588-1212 FAX: 1-514-286-8444
date so billings, claims and inquiries can be handled efficiently. [email protected] [email protected] [email protected] [email protected]

1. TO BE COMPLETED BY THE EMPLOYER

The below information is provided as standard guidelines. Please refer to your Contract/Booklet Name of Employer:

for specific terms and conditions of your policy. Policy Number: Division Number: Class:
Permanent Date Employed (DD/MM/YYYY): Eligible Date of Coverage (DD/MM/YYYY):
Occupation/Job Title:
SECTION 1 – TO BE COMPLETED BY THE EMPLOYER Employee Payroll Number (if applicable): Province of Employment:
This section is reserved for the employer as it requires specific information related to the Number of hours worked per week: Salary (before deductions): Frequency: m Annual m Monthly m Weekly m Bi-Weekly m Hourly

employee’s employment. HCSA Allocation $ (if applicable): PWA Allocation $ (if applicable):
Employment Type: m Full Time Hourly m Part Time Hourly m Full Time Salary m Part Time Salary m Contract/Temporary
Employer Signature: Date (DD/MM/YYYY):
SECTION 2 – EMPLOYEE AND FAMILY INFORMATION
2. EMPLOYEE AND FAMILY INFORMATION
Please ensure that the information in this section is completed correctly, as this information will Employee First Name: Employee Last Name:
be displayed on the identification card/identification card carrier. Sex*: m Male m Female m Intersex m Undisclosed Language Preferred: m English m French Date of Birth (DD/MM/YYYY):
Address (Street & Number):

The family information includes the employee’s spouse and all dependent children. If a dependent City/Town:
Telephone Number:
Province:
Employee E-mail Address:
Postal Code:

child exceeds the maximum dependent age per your Group Benefits Contract/Booklet and is Health / Dental Coverage: m Employee Only m Employee & Spouse m Employee & Family m Single Parent

attending an accredited educational institution as a full time student, student status is to be Modular/Flex options (Please indicate your chosen Module if you have a Modular/Flex plan):

selected to indicate College/University student. Spouse (if applicable)

First Name: Last Name:
Sex*: m Male m Female m Intersex m Undisclosed Birth Date (DD/MM/YYYY):
Selecting disabled indicates that the dependent has a disability, and a ‘Special Dependent Status: m Married m Common-Law Date of co-habitation if common-law (DD/MM/YYYY):

Questionnaire’ is to be completed in addition to the ‘Group Benefits Enrolment’ form. * Sex: Male/Female/Intersex/Undisclosed – Why do we ask? Some health conditions are more likely to occur based on sex. As a result, sex is used to assess your
coverage. We recognize that your sex may differ from your gender identity.
The ‘Special Dependent Questionnaire’ can be requested or printed from our Corporate Web Dependent Children (if applicable)
Last Name Date of Birth Sex Dependent Status
Site (www.medaviebc.ca). First Name (DD/MM/YYYY) M/F/I/U

mM mF m Disabled
m I mU m Student - College/University

If the employee is in a common-law relationship, indicate the date of co-habitation. A common- mM mF

m I mU
m Disabled
m Student - College/University

law spouse is considered a person with whom the employee has been residing for a minimum mM mF
m I mU
m Disabled
m Student - College/University
period at the time of enrolment and is publicly represented as a spouse. The standard co- If eligible, the Dependent Life benefit will be provided automatically if the dependent information is provided within this section or Section 4 - Beneficiary.
habitation period is 12 months. OTHER COVERAGE (CO-ORDINATION OF BENEFITS)
Do you or any of your dependents have coverage under any other Plan? m Yes m No If Yes, complete the following:
Name of the Other Insurer: Effective Date of Coverage (DD/MM/YYYY):
OTHER COVERAGE (COORDINATION OF BENEFITS) Policy Number: ID Number:
If the employee or his/her dependents have other Health/Dental coverage, provide the details of Type of Coverage: m Health - m Single m Family m Single Parent m Employee and Spouse

the plan and the type of coverage in order to coordinate both coverages. m Dental - m Single m Family m Single Parent m Employee and Spouse

3. WAIVER OF COVERAGE
All benefits under your group insurance plan are mandatory and provided to you based on the group contract. However, you may waive the health and dental
Claims for spouse with coverage must be submitted to his/her plan first. Claims for insured benefits if you have similar coverage under your spouse/common-law spouse’s plan.
m I have been given the opportunity to apply for coverage but do not wish to participate. I understand that I will not be able to enrol in these plans at a later
children must be submitted to the plan of the employee or spouse with the earlier date of birth in date without the mutual consent of my employer and Medavie Blue Cross. Also, I may be required to submit medical evidence of insurability at that time.

the year. m I understand that should I lose spousal coverage, and do not apply for coverage under this policy within 31 days of losing spouse/common-law spouse’s
plan, I may be required to submit medical evidence of insurability to apply for coverage under this policy after the afore mentionned period of 31 days.
I do not want to participate in the following coverage: m Health m Dental m Both Health and Dental

SECTION 3 – WAIVER OF COVERAGE For Quebec Residents: Participation in the Health coverage plan can only be declined due to spousal coverage. If declining the Health coverage,
please complete your spouse’s coverage information.
If the employee chooses to waive or decline their health and/or dental coverage due to having TM
The Blue Cross symbol and name are registered trademarks of the Canadian Association of Blue Cross Plans, used under licence by Medavie Blue Cross, an independent licensee of the Canadian Association of Blue Cross Plans.

alternate coverage, such as their spouse’s insurance plan, this section must be completed. * Trade-mark of the Canadian Association of Blue Cross Plans.

FORM-894E 09/24
† Trade-mark of Blue Cross Blue Shield Association. Blue Cross Life Insurance Company of Canada underwrites all life and disability benefits.
 GROUP BENEFITS

The Blue Cross symbol and name are registered trademarks of the Canadian Association of Blue Cross Plans, used under licence by Medavie Blue Cross, an independent licensee of the Canadian Association of Blue Cross Plans.
ENROLMENT FORM
DEFINED
Page 2

SECTION 4 – BENEFICIARY 4. BENEFICIARY

The beneficiary designation applies to Basic Life, Accidental Death and Dismemberment Any beneficiary(ies) designated below may be revocable or irrevocable at your choice.

coverages. Dependent Life benefits automatically defer to the employee as the designated A revocable designation can be changed at any time by completing and submitting a new designation form;
l

l
An irrevocable designation requires the written consent of the named irrevocable beneficiary in order to remove their name as beneficiary and/or change the
allocation amount (%). The beneficiary must be of the age of majority under the provincial jurisdiction of residence to provide the written consent.
beneficiary unless otherwise stated. If a legal beneficiary has not been appointed and the If the beneficiary designation is not specified, it will be considered revocable by default, with the exception of the Province of Quebec, the beneficiary designation of
beneficiary fields are left blank, benefits are paid to the estate of the deceased employee. a spouse is irrevocable by default, unless revocable is specified below.
Benefits are paid to the designated beneficiary(ies) below. If a legal beneficiary has not been appointed and the below fields are left blank, benefits are paid to the
Therefore, it is important to complete all fields accurately. estate of the deceased employee.
Primary Beneficiary(ies)
First Name Last Name Date of Birth Percentage Relationship Revocable Irrevocable
The sum of each percentage allocated to designated beneficiaries must total of 100%. (DD/MM/YYYY) (Must total 100%)

If a designated beneficiary is deemed irrevocable, the employee may not change their
beneficiary at any time. They require the said beneficiary’s written consent.
Contingent Beneficiary(ies): The individual(s) designated by the Employee to receive benefits in the event the primary beneficiary is deceased.
SECTION 5 – DIRECT DEPOSIT First Name Last Name Date of Birth Percentage Relationship Revocable Irrevocable
Direct Deposit enables your reimbursement to be automatically deposited into the bank account Contingent
(DD/MM/YYYY) (Must total 100%)

of your choice once your claim has been submitted and approved. The banking information can Beneficiary(ies)
Contingent
also be updated by using our Member Service Site or our Mobile App. Beneficiary(ies)

Trustee: A person given control or powers of administration of property held in trust with a legal obligation to administer it solely for the purposes specified. For
designated beneficiaries considered a minor, a Trustee is to receive any amount due for any beneficiary considered a minor under the provincial jurisdiction of residence.
Direct Deposit can be cancelled at any time by providing a 30 days written notice to Medavie First Name Last Name Date of Birth Relationship Revocable Irrevocable
Blue Cross. (DD/MM/YYYY)

Blue Cross Life Insurance Company of Canada underwrites all life and disability income benefits.
Trustee

For the Province of Québec, where the beneficiary of a life insurance policy is a minor at the time of the insured’s death, Medavie Blue Cross will pay the proceeds to
SECTION 6– PRIVACY CONSENT parent(s) (or other legal guardian, if applicable), and not to anyone else who might be named as administrator/trustee of the proceeds. If you wish to have another
person administering the child’s proceeds, you should have the proper provisions in your will. You may also want to consult with a legal counsel to determine whether
The Privacy Consent agreement is obtained at time of enrolment and also at time of claim there is some estate planning steps you can take to support your wishes.

through the use of detailed consent statements on our standard forms. An individual may revoke 5. DIRECT DEPOSIT

their consent at any time, however, in certain situations this could result in our inability to provide I may cancel this authorization at any time by giving 30 days written notice to Medavie Blue Cross.
Name(s) of Account Holder
coverage. (as it appears on the cheque): Branch/Transit
Number
Financial
Institution
Number
Account
Number

Name of Financial Institution:

SECTION 7 – AUTHORIZATION Address of Financial Institution:

Financial Institution Number (3 digits): Branch/Transit Number (5 digits):
In order for the enrolment to be processed by Medavie Blue Cross, signatures from the employee Account Number (7 - 14 digits):
as well as the employer along with the date must be completed within the Authorization section. (If your Account Number starts with a zero, be sure to include the zero. Do not Include dashes, hyphens or any other punctuation.)

6. PRIVACY CONSENT
I understand that the personal information I have provided herein is collected and used by Medavie Blue Cross to administer the terms of my policy or the group policy of which I am an eligible member, recommend suitable

SECTION 8 – PRESCRIPTION DRUG INSURANCE (QUEBEC ACT) products and services that I am eligible for as a member of a policy, and other applicable purposes, as described in the Medavie Blue Cross Privacy Statement at medaviebc.ca.
Depending on the type of coverage I carry, limited personal information such as claim, health and/or financial related data may be collected from and/or released to following third parties as required for the purposes of

If you are a resident of Quebec, please ensure to review the prescription drug act guidelines. administering and managing the benefits outlined in the policy of which I am an eligible member. These third parties may include healthcare providers, other insurance companies, regulatory authorities and investigative
bodies, services providers, and/or the cardholder of any contract under which I am a participant.
Where allowed by law, my information may be shared with Medavie Blue Cross employees or service providers in jurisdictions other than where it was collected. If I am a resident of Quebec, this includes transferring or
disclosing my personal information to Medavie Blue Cross employees or service providers outside of that province.
I understand that my consent is only valid for the time it is needed to achieve the purposes outlined herein, unless I withdraw it. I understand I may withdraw my consent at any time. However, in some instances doing so may
prevent Medavie Blue Cross from providing me with certain products or services that may be useful to me and/or my dependents. This consent complies with federal and provincial privacy laws.
For more details about our information practices, including how your personal information is protected, how to access or correct personal information, or if you have concerns or questions, please see our Medavie Blue Cross
Privacy Statement available at medaviebc.ca or call 1-800-667-4511.

TM
7. AUTHORIZATION
I certify that the information above is accurate and authorize payroll deductions, if required. I authorize Medavie Blue Cross and/or Blue Cross Life to collect, use and
disclose my personal information as described in the Privacy Consent section above.
Employee Name (please print):

Employee Signature: Date (DD/MM/YYYY):

8. PRESCRIPTION DRUG INSURANCE (QUEBEC ACT)

FORM-894E (Explanation) 09/24

All persons under 65 years of age who have access to a group insurance plan must enrol in the plan unless they already participate in another group plan or have insurance under a spouse’s group plan.
Proof of coverage must be kept on file with the employer.
By enrolling in your employer’s group insurance plan, you are required to also arrange for coverage for all eligible dependents unless they are already covered under another group insurance plan.
Your dependents do not qualify for coverage under the RAMQ’s basic prescription drug insurance plan if you already have coverage under an employer’s group plan with the exception of a spouse aged 65
years or over.
When you complete your income tax return, you will be asked to confirm that you have complied with the provisions of the Act.