CHANGE FORM

644 MAIN ST PO BOX 220 230 BROWNLOW AVE DARTMOUTH PO BOX 2000, 185 THE WEST MALL SUITE 1200 1981 MCGILL COLLEGE AVENUE, SUITE 100
MONCTON NB E1C 8L3 PO BOX 2200 HALIFAX NS B3J 3C6 ETOBICOKE ON M9C 5P1 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
[email protected] [email protected] [email protected] [email protected]

Instructions:
1) Earnings information is only required if life and/or income replacement benefits apply.
2) The Optional Group Life Insurance Statement of Health and Smoking Questionnaires must be completed when an ADD or CHANGE is requested for Optional Life or Optional Critical
Illness benefits. The actual amount of coverage must be stated (not the amount of the increase / decrease).

THIS AREA MUST BE COMPLETED FOR CHANGES TO BE PROCESSED

Existing ID Number: Payroll Number:
Existing Policy and Division Number: Last Name:
1. TYPE OF CHANGE - CHECK ( 3)
m Address m Marital Status m Beneficiary m Left Employ m Cancel Benefits: Reason
m Dependent(s) m Retired m Telephone No. m Salary m Add Benefits: Reason
m Benefits m Deceased m Occupation m Transfer m Other:

2. COMPLETE ONLY AREAS AFFECTED BY THE CHANGE AND SIGN

Employee First Name: Employee Last Name:
Address (Street & Number):
City/Town: Province: Postal Code:
Date of Birth: Telephone Number: Language Preferred: m English m French
Spouse (if applicable) m ADD m CHANGE m DELETE
First Name: Middle Initial: Last Name:
Sex*: m Male m Female m Intersex m Undisclosed Birth Date (DD/MM/YYYY):
Status: m Married m Common-Law Date of co-habitation if common-law (DD/MM/YYYY):
* 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.
Dependent Children (if applicable)
Date of Birth Sex A - Add
First Name Last Name Dependent Status C - Change
(DD/MM/YYYY) M/F/I/U D - Delete
mM mF m Disabled
mA mC mD
m I mU m Student - College/University
mM mF m Disabled
mA mC mD
m I mU m Student - College/University
mM mF m Disabled
mA mC mD
m I mU m Student - College/University

OTHER COVERAGE (CO-ORDINATION OF BENEFITS) m ADD m CHANGE m DELETE

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):
Policy Number: ID Number: Type of Coverage: m Hospital m Vision m EHB m Drugs m Dental m All
Name of Employer:
Date of Birth Date of Birth
Name of Person(s) insured under other policy DD MM YYYY Name of Person(s) insured under other policy DD MM YYYY

BASIC COVERAGE m ADD m CHANGE m DELETE

m Life m Long Term Disability m Dependent Life m Health m AD & D m Weekly Indemnity m Dental m Critical Illness
Dependent life is automatically included if you indicate family status and eligible dependents.
m HCSA Allocation $ m PSA Allocation $

STATUS CHANGE m Single m Family

3. OPTIONAL COVERAGE (PLEASE CONFIRM APPLICABLE BENEFITS WITH YOUR GROUP ADMINISTRATOR)
OPTIONAL COVERAGE m ADD m CHANGE m DELETE

If applying for Optional Coverage, the Non-Smoker Questionnaire and/or the Statement of Health may also be required.
Do you use tobacco products? m Yes m No

Answer “No” if you have not used any nicotine or used any smoking cessation products in any form (including e-cigarettes) in the past 12 months.
Optional Life: m Employee Employee Amount $ m Spouse Spouse Amount $
Optional Dependent Child Life: Amount $
Optional Critical Illness: m Employee Employee Amount $ m Spouse Spouse Amount $
m Child Child Amount $

Optional Accidental Death & Dismemberment: m Employee Only m Employee & Family Amount $
 4. COMPLETE ONLY AREAS AFFECTED BY THE CHANGE AND SIGN

CHANGE OF BENEFICIARY
In accordance with the terms and conditions of the Group Life Contract between the employer indicated below and Blue Cross Life Insurance Company of
Canada, I revoke all previous appointments of beneficiary and hereby appoint the following as beneficiary entitled to receive the proceeds arising by reason
of my death. Surviving beneficiaries will share equally unless otherwise indicated.
First Name Last Name Percentage Relationship Revocable Irrevocable
(Must total 100%)

m m
m m
m m
m m

First Name Last Name Date of Birth Percentage Relationship Telephone Number
(DD/MM/YYYY) (Must total
100%)
Contingent
Contingent
For designated beneficiaries considered a minor: I appoint as Trustee to receive any
amount due for any beneficiary considered a minor under the provincial jurisdiction of residence.
By choosing irrevocable, no future changes to your beneficiary designation will be permitted without the written consent of that beneficiary(ies) when the
beneficiary(ies) is/are the age of majority.
IN QUEBEC, THE DESIGNATION OF YOUR SPOUSE AS BENEFICIARY IS PRESUMED IRREVOCABLE UNLESS OTHERWISE SPECIFIED.
For the province of Quebec - 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 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 ensure you have the proper provisions in your will. You may also want to consult with a legal counsel to determine
whether there are some estate planning steps you can take to support your wishes.
MARITAL CHANGE
When an employee requests a change from single to family coverage within 31 days of marriage, family coverage will become effective as outlined in the
Medavie Blue Cross group benefits contract. If later than 31 days, a Statement of Health form may be required.

Date of change in Marital Status (DD/MM/YYYY):

If Spouse has Medavie Blue Cross benefits, please complete:

Policy Number: Identification Number: Last Name:

AUTHORIZATION OF CHANGE
I certify that the information above is accurate and authorize payroll deductions, if required. I authorize Blue Cross to collect, use and disclose my personal information.
I understand that the personal information provided herein, as well as any other personal information currently held or collected in the future by Medavie Blue Cross
and/or Blue Cross Life Insurance Company of Canada, may be collected, used, or disclosed to administer the terms of my policy or the group policy of which I am an
eligible member, to recommend suitable products and services to me, and to manage Blue Cross’s business. Depending on the type of
coverage I carry, limited personal information may be collected from and/or released to a third party. These third parties include other Blue Cross
organizations, health care professionals or institutions, life and health insurers, government and regulatory authorities, and other third parties when required
to administer and manage the benefits outlined in the policy of which I am an eligible member.
I understand that my personal information will be kept confidential and secure. I understand that I may revoke my consent at any time, however, in some instances doing
so may prevent Blue Cross from providing me with the requested coverage or benefits. I understand why my personal information is needed and I am aware of the risks
and benefits of consenting or refusing to consent to its disclosure.

A photocopy of this authorization shall be as valid as the original. This consent complies with federal and provincial privacy laws. For additional information regarding
privacy policies at Medavie Blue Cross, visit medaviebc.ca or call 1-800-667-4511.

Employee Signature: Date:

Witness Signature: Date:

5. TO BE COMPLETED BY EMPLOYER
Name of Employer: Policy and Division Number:
Class of Coverage - Health and/or Dental: Employee Class - Life and/or Disability Income:
Occupation: Effective Date of Change (DD/MM/YYYY):
Complete for Life and Disability Income Benefits: Earnings per m Hour m Month m Week m Year $ Hours Worked Per Week:
Payroll Number (Maximum 9 positions): (1) (2)

Completed for Employer by:

Signature: Date:

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.
* Trade-mark of the Canadian Association of Blue Cross Plans. † Trade-mark of Blue Cross Blue Shield Association.

FORM-048E 12/21