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Common Law Spouse Declaration |
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Use
If you have listed a common law spouse as a dependent on your Health Benefit
Plan Enrolment Card, you may be required to complete the Common Law Spouse Declaration form
and submit with your enrolment card for your common law spouse to be eligible
for Extended Health and Dental coverage.
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Information Needed to Complete the Form
To complete the form, the following information is needed:
- Member's name and address,
- Common law spouse's name,
- Address at which you are currently residing, and
- Signature of a Notary Public or Commissioner for taking Affidavits.
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Notes
A licensed Notary Public or Commissioner must sign the form before you send it
to the Plan Administrator.
Questions on completing the form should be directed to the Plan
Administrator.
Completed forms should be forwarded to the Plan
Administrator.
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Plan Administrator
D.A. Townley & Associates Ltd.
101 – 4190 Lougheed Highway
Burnaby, BC V5C 6A8
Phone: 604-299-7482 or 1-800-663-1356
Fax: 604-299-8136
Email
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PDF
- 50 Kb)