Please complete all sections of this form.
Data has been revised – use for any data changes / Employer Name
Date of revision: / Employer representative initials: / Date of death
Note: Date format is dd-mmm-yyyy
A / Member Information
Last Name / First Name / Initial / Social Insurance Number
Date of birth / Sex / Phone number
M / F
Mailing Address
B / Earnings, contributions and pensionable service
Start date of pay period for first pay of the year / Last day worked
Please submit your contribution calculation worksheet along with this application.
Current Year / Previous Year
(if DCT has not been submitted)
Regular contributory earnings
Does not include earnings for purchased leaves, lump sum or retroactive pay.
Report the last two amounts separately below. / $ / $
Lump sum contributory earnings / $ / $
Retroactive Pay
Prior to reporting year. Attach Retro Pay Allocation form from the CAAT Plan website / $ / $
Total Earnings
Combined total of all three rows above / $ / $
Basic Contributions
Does not include purchased leaves / $ / $
RCA contributions / $ / $
Annual rate of salary / $ / $
Pension Adjustments (PA)
Include current year purchased leaves / N/A / $
Pensionable Service
Total service, excluding purchased service, used for PA calculation (5 decimals)
Pensionable service details in current year – OTRFT only (if member has more than 3 jobs in the year, attach a page with details)
Job #1 / Job #2 / Job #3
Hours Worked
FTE for job
Earnings details – full-time members only
Report the contributory earnings for the period of service in the first year of the final 5 year period of employment. The first year will be 5 years before the current year. For example, if the member’s last day worked is August 2, 2013, report earnings paid in 2008 starting on August 3, 2008 (you may have to split a pay period to get these earnings), up to the last pay in the calendar year (which does not necessarily coincide with December 31, 2008).
From / To / Year / Earnings
Contributory Earnings
In first year of final 5 years
CAAT Pension Plan 250 Yonge Street, Suite 2900, Toronto ON M5B 2L7Tel: 416.673.9000 Toll Free: 1.866.350.2228 Fax: 416.673.9028
Remember: never send member information by email – always use S-Doc.
TRD-311-01-E
CAAT Pension Plan Death Benefit Application 2/2
Member Last Name / First Name / Initial / Social Insurance NumberC / Leaves
Report any leaves of absence for the current year (and the previous year if the DCT has not been submitted). Indicate the leave type.
Ensure the applicable service purchase form and the payment is submitted for all leaves included below, including those currently in the process of being purchased.
There are no unreported leaves for the current or previous year.
Leave of Absence or Pregnancy / Parental Leave Purchased? / Start Date / End Date / Leave Type
Yes No
Yes No
Yes No
D / Death Details
Date of death
Please provide a copy of the Death Certificate
Member with spouse
Spouse Definition: A person who is the legally married spouse or the qualifying common-law spouse of a member provided they are not living separate and apart.
Please provide the following information about the spouse. Ask the spouse to sign the Spouse Authorization below.
Last name / First name / Sex (M/F) / Date of birth
Date of marriage/common-law / Spouse Social Insurance Number
Member with no Spouse, but with eligible children
Please provide the names and dates of birth of all the eligible children (under age 18) and the name and contact information for the guardian.
Child’s full name / Date of birth / Child’s full name / Date of birth
Guardian name / Phone number
Mailing address
Member with no spouse and no eligible children
Member has no known spouse or children / Provide the name and address of a representative of the estate of the deceased member, if known.
Full Name / Phone Number
Mailing Address
E / Spouse Authorization
I certify that I am the spouse of the deceased member for the purposes of the CAAT Pension Plan.
I authorize the Plan and its agents to collect, share and use my personal information as may be needed for the purposes of calculating and paying pension benefits and activities related to the administration of the Plan. Personal information is collected, used and maintained by the Plan in accordance with its privacy policy available at
Signature / Date
F / Employer Representative Authorization
The information provided on this form is correct according to the employer’s records. Any required supporting documents are attached.
Representative Name / Representative Signature / Date
CAAT Pension Plan 250 Yonge Street, Suite 2900, Toronto ON M5B 2L7Tel: 416.673.9000 Toll Free: 1.866.350.2228 Fax: 416.673.9028
Remember: never send member information by email – always use S-Doc.
TRD-311-01-E3 1111111111111111111111111111111111111111111111111111