TRANSACTION TYPE (Employer Use Only)

TRANSACTION TYPE (Employer Use Only)

Return completed form to Human Resources

/ EMPLOYER USE ONLY / Y / Y / Y / Y / M / M / D / D
New Plan Member (first day of coverage) / - / -
Rehire (first day of coverage) / - / -
Plan Change (first day of new coverage) / - / -
Add Dependent (first day of coverage) / - / -
Terminate Dependent (first day of NO coverage) / - / -
Employee #
Cost Centre
Package #
Surname / First Name / Initial
Birth date / YYYY / MM / DD / Marital Status / Single / Married / Common Law / Since / YYYY / MM /DD
Hire Date / YYYY / MM / DD / Male / Female / Benefit coverage / Single / Family
Mailing Address
Street P.O. Box, RR. #
City / Province / Postal Code
Y / N / Dental
Y / N
Does your spouse have Health or Dental coverage elsewhere? And if so, is that coverage single, or family?
If coverage is with Green Shield, please provide the GS ID#: / Single
Family / Single
Dep. / Surname (if different
than Plan Member) / Legal First Name / Preferred First name / Initial / Birthdate
(YYYY/MM/DD) / Gender / IN-SCHOOL DECLARATION: If dependent child is between 19-24 yrs of age, confirm full-time attendance
Spouse / YES / NO / Proof on file? Y/N
1st Child
2nd Child
3rd Child
4th Child
5th Child

By signing this enrolment form or by providing my personal information to my employer, I agree the information is complete and accurate to the best of my knowledge. I am authorized to release information concerning my spouse and my dependents, for the purpose of determining eligibility for benefits. I certify that I am authorized by my spouse and/or dependents to disclose and receive information about them that is used for these purposes. For further information on our privacy policy and procedures,please refer to your benefit plan booklet.

Employee Signature / Date

Please read these special notes carefully since incorrect or incomplete enrolment information could result in denial or improper payment of your claims. Complete each section according to the instructions listed below and sign the bottom of the form when you are sure that the information is complete and accurate. Incomplete forms will be returned.

TRANSACTION TYPE (Employer use only)

1) Mark the appropriate box to indicate one or more of the transaction types shown along with the effective date.


1) Print your name and full mailing address in the designated areas. Please record the first name by which you will refer to yourself when submitting claims. (ie. If you will use Robert on your claims, don’t use Bob when completing this form).

2) Enter birth year, then mark the appropriate box to indicate sex (male or female) and family status (single, couple, family).


If your family members have other benefit coverage they will be co-ordinated according to industry standards.

Joint custody

If the parents have joint custody and both have the children listed as dependents under their plan, then the claims should be submitted first to the plan of the parent whose birth month and date is earlier in the calendar year.

Separation or divorce

Children may qualify as dependents of several adults related to them either naturally or through marriage. In situations of separation or divorce, the following order applies when determining which of the adults are responsible for the coverage of the children:

1) the plan of the parent with custody of the child

2) the plan of the spouse of the parent with custody of the child

3) the plan of the parent not having custody of the child

4) the plan of the spouse of the parent in 3) above.



1) Print the surname and full name of each person eligible to be covered under your employer’s benefit policies. Be sure to use the first name which will be used when submitting claims

(ie. If Betty will be used when submitting claims, don’t use Elizabeth when completing this form).

2) Enter “M” (male) or “F” (female) to identify the sex of each dependent.

3) Enter the full date of birth for each dependent. Please confirm the accuracy of these birth dates, since they will affect claims payment and dependent eligibility.



Eligible spouse:

-The person legally married to you, or

-A person who is publicly represented by you as your spouse (including same sex spouse)

In the event that an Employee/pensioner takes up residence with an individual and publicly represents that individual as his or her spouse, the spouse status of any other individual is to be terminated by the employee/pensioner. Only one person shall be considered a qualified dependent spouse during a period of time for which any benefits are payable to or for the spouse of an employee/pensioner. An individual who ceases to qualify as a spouse is no longer eligible for benefits. Divorced spouses of employees/pensioners are NOT eligible for health and dental coverage.

Eligible children:

Children who are:


-Unemployed, and

-Attending school full-time up to and including 23 years of age.

Coverage ceases as of the child’s 24th birthday or if any of the other above criteria are not satisfied. Children includes any child of the employee/pensioner or their spouse and legally adopted children. Children includes a child of any age who is dependent for financial support up on the Employee/Pensioner or the Employee’s/Pensioner’s spouse because of physical or mental infirmity, provided infirmity commenced while the individual otherwise met the definition of an eligible child as outlined above.