To:All Eligible Employees

MEMORANDUM

To:All Eligible Employees

From: Human Resources

Date:October 2014

Subject:Group Benefits Enrollment

You have completed the benefit waiting period. Accordingly, an enrollment application is enclosed for your review. After completing the enrollment form, please contact Carrie Duchesne, Benefits Advisor, with questions, comments or concerns you may have regarding group benefits.

This form must be returned to Human Resources in order to advise us of your choice regarding single or family coverage for group benefits.

Yes, I want to have family coverage under the group benefits plan. I understand that if I do not elect family coverage at this time and require family coverage at a later date, I must apply with Nipissing within 31 days of a qualifying event. I understand if I do not report such event within 31 days, my dependents must fill out a health questionnaire to be reviewed by the benefits carrier before benefits can be granted. Approval may be denied under our group benefit plan. I understand that the personal information that is collected by the University will be kept strictly confidential and will only be used, exchanged and retained for the purpose for which it was collected.
Yes, I want to have single coverage under the group benefits plan. I have eligible dependents, but choose single coverage even though I understand Coordination of Benefits. I understand that I will have single health and dental coverage, as well as Dependent Life insurance. I understand our group insurance contract deems that enrollment in the Dependent Life insurance is mandatory if you have eligible dependents. I understand that if I require family coverage at a later date, I must apply with Nipissing within 31 days of a qualifying event. I understand if I do not report such event within 31 days, my dependents must fill out a health questionnaire to be reviewed by the benefits carrier before benefits can be granted. Approval may be denied under our group benefit plan. I understand that the personal information that is collected by the University will be kept strictly confidential and will only be used, exchanged and retained for the purpose for which it was collected.
Yes, I want to have single coverage under the group benefits plan. I have no dependents. I understand that if I acquire dependents (marriage, birth, adoption, etc.) I must apply with Nipissing within 31 days of a qualifying event. I understand if I do not report such event within 31 days, my dependents must fill out a health questionnaire to be reviewed by the benefits carrier before benefits can be granted. Approval may be denied under our group benefit plan. I understand that the personal information that is collected by the University will be kept strictly confidential and will only be used, exchanged and retained for the purpose for which it was collected.

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SignatureDate

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Human Resources

H:\USER\HRPOSI\GWL\FORMS\Enrollment Memo - Oct 2014.doc