Grandeur Group Enrollment Form Grandeur Group Enrollment Form EMPLOYMENT INFORMATION [TO BE COMPLETED BY YOUR PLAN ADMINISTRATOR] – COMPLETE ALL SECTIONSGROUP NAME [EMPLOYER](Required) DIVISION CLASS CLIENT ID [LEAVE BLANK] MEMBER DATE OF HIRE/RE-INSTATEMENT [MM/DD/YYYY] MM slash DD slash YYYY SALARY [ANNUAL]NUMBER OF HRS WORKED PER WEEK SALARY TYPE hourly monthly bi-weekly semi-monthly annual OCCUPATION APPLY WAITING PERIOD YES NO [IF NO PLEASE PROVIDE REASON FOR WAIVING THE WAITING PERIOD]EMPLOYEE INFORMATION [PLAN AND IDENTIFICATION NUMBERS ARE ASSIGNED ONCE ENROLMENT IS COMPLETED]EMPLOYEE FIRST NAME(Required) EMPLOYEE LAST NAME(Required) GENDER Male Female DATE OF BIRTH [MM/DD/YYYY](Required) MM slash DD slash YYYY MARITAL STATUS SINGLE MARRIED COMMON LAW ADDRESS CITY PROVINCE POSTAL CODE PHONE [INCLUDE AREA CODE] E:MAIL LANGUAGE English French DEPENDENT COVERAGE REQUIRED Yes No IF NO PLEASE SPECIFY REASON SPOUSE FIRST NAME: SPOUSE LAST NAME: SPOUSE DATE OF BIRTH: D/M/YYYYGENDER: Male Female CHILD FIRST NAME: CHILD LAST NAME: CHILD DATE OF BIRTH D/M/YYYYGENDER: Male Female CHILD FIRST NAME: CHILD LAST NAME: CHILD DATE OF BIRTH: D/M/YYYYGENDER: Male Female CHILD FRIST NAME: CHILD LAST NAME: CHILD DATE OF BIRTH: D/M/YYYYGENDER: Male Female CHILD FIRST NAME: CHILD LAST NAME CHILD DATE OF BIRTH: D/M/YYYYGENDER: Male Female If you or your spouse are covered for extended health care and/or dental care benefits by another plan please indicate coverage type: Extended Health Care: None Single Family If you or your spouse are covered for extended health care and/or dental care benefits by another plan please indicate coverage type:Dental: None Single Family NAME OF SPOUSE’S EMPLOYER NAME OF SPOUSE’S INSURANCE COMPANY POLICY/PLAN NUMBER REFUSAL OF EXTENDED HEALTH AND DENTAL BENEFITSIf You Or Your Dependents Are Presently Covered For Extended Health And/Or Dental Benefits Under Another Group Insurance Program You May Refuse Coverage By Selecting The Appropriate BoxesI Refuse Coverage For Myself, My Spouse And My DependentsI Refuse Coverage For Myself, My Spouse And My Dependents Extended Health Dental I Refuse Coverage For My Spouse And Dependents HiddenI Refuse Coverage For My Spouse And Dependents Extended Health Dental I Refuse Coverage For My Spouse And Dependents I Refuse Coverage For My Spouse And Dependents Extended Health Dental BENEFICIARY INFORMATION – ALL INFORMATION IS REQUIRED Beneficiary Information: I hearby assign the following individual(s) as my beneficiary. Your beneficiary will automatically default to your "Estate" if you fail to complete this section. Unless otherwies stipulated or prohibited by law, the designation is Revocable. If the Beneficiary is shown as Irrevocable, his/her consent is required to change it. All Beneficiary Information is Required: FIRST NAME: LAST NAME: DATE OF BIRTH [MM/DD/YYYY]: MM slash DD slash YYYY RELATIONSHIP STATUS: PERCENTAGE [MUST TOTAL 100%]: FIRST NAME: LAST NAME: DATE OF BIRTH [MM/DD/YYYY]: MM slash DD slash YYYY RELATIONSHIP STATUS: PERCENTAGE [MUST TOTAL 100%]: FIRST NAME: LAST NAME: DATE OF BIRTH [MM/DD/YYYY]: MM slash DD slash YYYY RELATIONSHIP STATUS: PERCENTAGE [MUST TOTAL 100%]: FIRST NAME: LAST NAME: DATE OF BIRTH [MM/DD/YYYY]: MM slash DD slash YYYY RELATIONSHIP STATUS: PERCENTAGE [MUST TOTAL 100%]: If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change.If you name an irrevocable beneficiary and wish to change it at a later date, the current beneficiary would be required to approve the change REVOCABLE IRREVOCABLE Note: If beneficiary is shown as irrevocable, his/her consent is required to change it. Include a signed and dated consent with this form. You are responsible for ensuring the validity of your designation.FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is:FOR QUEBEC RESIDENTS ONLY - In Quebec, the designation of your spouse as beneficiary is irrevocable unless otherwise specified. If spouse is beneficiary, designated is: REVOCABLE IRREVOCABLE TRUSTEE DESIGNATION: This section is to be completed only if the beneficiary designated above is under the age of majorityTRUSTEE NAME [Trustee to receive any amount due to any beneficiary under the age of 18] RELATIONSHIP STATUS DECLARATION & AUTHORIZATION – MUST SIGN AND DATEI disclose the person name(s) under Beneficiary Designation as the appointed Beneficiary (s). I confirm that the information provided on this form is true and complete, and understand that if any of the information is incomplete or false my benefits can be terminated. I acknowledge that I am authorized to disclose and receive information about my spouse and/or dependents. the Plan Administrator, its agents, insurers and service providers are authorized to use and exchange information on this form to underwrite, administer, determine eligibility and adjudicate claims. I understand that Personal Information collected with this Application for Insurance is confidential and will not be used or any purpose other than in conjunction with this request form, and subsequent administration of, the Group Insurance protection that is afforded to Applicants, Spouses, and Dependent Children under this plan. I authorize the Plan Administrator to recover any payments made in error.APPLICANT’S SIGNATURE:(Required)DATED:(Required) MM slash DD slash YYYY PRIVACY & CONFIDENTIALITYWe protect our Customers’ confidential information. A combination of industry, legislated and our own corporate privacy and confidentiality requirements govern the level of detail shared about any plan member and his or her dependents’ benefits. In terms of telephone inquiries to the Plan Administrator, Customer Service, the information provided varies based on the relationship of the person making the inquiry to the insured (e.g. plan administrator, plan member or dependent). After the caller has been screened for appropriate identification, only the information pertaining to the specific claim or treatment in question is shared. EMPLOYER AUTHORIZATION – MUST SIGN AND DATEI declare that the information provided above is accurate and true, and hereby authorize the Plan Administrator to use this information to administer the Group Benefits; obtain quotes for underwritten/insured products within the plan; verify the identity and eligibility of the plan member, spouse or eligible dependents; adjudicate and pay eligible claims; audit plans and prepare reports. I understand that this information will only be provided to those insurers affiliated with the Plan Administrator and acknowledge that I have obtained the consent of this Employee and Spouse/Partner to provide this information.EMPLOYER’S SIGNATURE:DATED: MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
