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Change Card |
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Use
Use a Group
Insurance Change Card to change dependent and coordination
of benefit information and to opt in or out of optional
benefit coverages (if allowed under your Plan). This form
should also be used to record all changes to personal Member
information after you have initially enrolled in your Plan.
Members should use the Group
Insurance Enrolment Card to initially enrol in their Plan.
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Information Needed to Complete the Form
Your personal Member information is needed to complete the card. In addition you will
need:
- Dependent information,
- Beneficiary information,
- Other Plans that provide Health and/or Dental coverage to you, and
- Optional coverage that you are applying for or deleting (if allowed by your Plan).
Please follow the instructions on the form.
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Notes
If you are covered for MSP through your Plan, you must complete a separate
MSP Group Change Form to update
your MSP coverage.
Questions on completing the form should be directed to the
Plan Administrator.
Completed forms should be forwarded to your Human Resources
Department. |
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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
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