CHANGE REQUEST FORM
PLEASE USE BLOCK LETTERS, TYPE OR PRINT WHEN
COMPLETING THIS FORM
GENERAL INFORMATION (TO BE COMPLETED BY EMPLOYEE)
Member/Employee Name
Member Number
EMPLOYER/COMPANY NAME
Member Tax Registration Number
CHANGE OF DEPENDENT STATUS - LIST DETAILS BELOW (TO BE COMPLETED BY EMPLOYEE)
TELL US WHAT YOU WOULD LIKE TO BE CHANGED
Cancel all Dependent Coverage Cancel Dependent Coverage (as listed below) Add Dependent(s) (as listed below)
D D M M M Y Y
Effective Date of change
LAST NAME FIRST NAME MI SEX RELATIONSHIP DATE OF BIRTH TRN
M F D D M M M Y Y
M F D D M M M Y Y
M F D D M M M Y Y
M F D D M M M Y Y
REASON FOR ADDITION OF DEPENDENT COVERAGE: REASON FOR DELETION OF DEPENDENT COVERAGE:
MARRIAGE DIVORCE/DEATH OF DEPENDENT
BIRTH OF CHILD COMMENCEMENT OF DEPENDENT EMPLOYMENT
OTHER (Specify) OTHER (Specify)
(sumbit supporting documents)
I agree to any change in contribution necessitated by the requested change in coverage.
CHANGE/CORRECTION OF NAME (TO BE COMPLETED BY EMPLOYEE)
PLEASE CHANGE THE NAME OF THE : EMPLOYEE DEPENDENT
FROM (NAME CURRENTLY ON FILE):
LAST NAME FIRST NAME MI
TO (INTENDED NAME):
(sumbit supporting documents) LAST NAME FIRST NAME MI
REASON FOR NAME CHANGE: MARRIAGE OTHER (SPECIFY)
CORRECTION OF DATE OF BIRTH/GENDER
PLEASE CHANGE THE DETAILS OF THE: EMPLOYEE DEPENDENT NAME
D D M M M Y Y M F
FROM (date currently on file): FROM (gender currently on file):
DATE OF BIRTH GENDER
TO (intended date): D D M M M Y Y M F
(sumbit supporting documents) TO:
DATE OF BIRTH GENDER
APPOINTMENT/CHANGE OF BENEFICIARY
I do hereby revoke any previous designation or appointment of beneficiary(ies)
with respect to said Group Life Policy and now designate and appoint as indicated below:
BENEFICIARY NAME RELATIONSHIP LIFE% DATE OF BIRTH GENDER TRUSTEE NAME
D D M M M Y Y M F
D D M M M Y Y M F
D D M M M Y Y M F
D D M M M Y Y M F
SIGNATURE OF EMPLOYEE DATE SIGNATURE OF WITNESS
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CHANGE REQUEST FORM
(If employee is applying for coverage outside of eligibility period, please complete the Health History Questionnaire)
HEALTH HISTORY QUESTIONNAIRE
THIS HEALTH HISTORY QUESTIONNAIRE IS BEING COMPLETED FOR: Employee Only Employee & Dependents Dependent(s) only
NAME HEIGHT WEIGHT GENDER RELATIONSHIP DATE OF BIRTH TRN
M F D D M M M Y Y
M F D D M M M Y Y
M F D D M M M Y Y
M F D D M M M Y Y
PERSONAL HEALTH HISTORY (TO BE COMPLETED BY EMPLOYEE)
(NOTE: IF QUESTIONNAIRE IS BEING COMPLETED FOR NEW DEPENDENTS, GIVE DETAILS ONLY FOR DEPENDENTS)
FOR THE EMPLOYEE YES NO
1. Are you employed by the employer named on this form for more than 30 hours per week?
FOR THE EMPLOYEE AND/OR DEPENDENTS KINDLY RESPOND ‘YES’ OR ‘NO’ TO THE FOLLOWING QUESTIONS.
2. During the last 5 years, have you or any of your dependents consulted, been examined or treated by a Doctor, or been advised to
have any diagnostic tests (e.g. blood tests, X-Rays, CAT Scan, MRI) etc.?
3. During the last 5 years, have you or any of your dependents undergone a surgical operation, or been treated in any hospital or
other institution?
4. Have you or any of your dependents been treated for, or been told that you have Heart Trouble, Blood Disease, High Blood
Pressure, Kidney Disorder, Diabetes, Tuberculosis, Cancer, Tumor, Ulcer, Asthma, Epilepsy, Alcoholism, Mental Disorder, or any
other disease not listed anywhere on this application?
5. Have you or any of your dependents been diagnosed with, or treated for HIV, AIDS, or ARC (AIDS related complications) (If
‘Yes’, underline disease.)
6. Are you or any of your dependents now receiving, contemplating, or been advised to seek any medical attention or
surgical treatment, or taking any medication?
7. Do you or any of your dependents have any disorder of the female organs or breast?
8. Are you or any of your dependents now pregnant?
9. Do you or any of your dependents have any physical impairments?
10. Do you or any of your dependents have any prior or existing history of alcoholism or drug abuse?
11. Have you or any of your dependents ever had an application for Life or Health Insurance declined,
postponed, rated or modified in any way?
IF THE RESPONSE TO ANY OF QUESTIONS 2-11 IS ‘YES’, GIVE COMPLETE DETAILS BELOW (CONTINUE ON ANOTHER SHEET,
IF NECESSARY)
QUESTION FULL NAME OF PERSON NATURE OF AILMENT DEGREE OF RECOVERY: (FULL, NAME AND ADDRESS OF ATTENDING MEDICAL DATE OF
NO. TREATED PARTIAL OR CONTINUING) PROFESSIONAL VISIT
I declare that all the statements on this form are full, true and complete, and I understand that they form the basis upon which any insurance will be made effective. I
authorize the physician, hospital or other medically related facility to disclose to Canopy Insurance Limited information about my health, habits or medical history, as well
as that of any dependents listed above. It is further understood that Canopy Insurance Limited reserves the right to request an examination by a Physician of their choice
to aid its decision.
SIGNATURE OF EMPLOYEE DATE
NAME OF AUTHORIZED OFFICER OF EMPLOYER POSITION OF AUTHORIZED OFFICER OF EMPLOYER
SIGNATURE OF AUTHORIZED OFFICER OF EMPLOYER DATE
COMPANY STAMP
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