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Enrolment Card and Beneficiary Designation |
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Use
Complete a Group
Insurance Enrolment Card to enrol in your Health Benefit
Plan, enrol your dependents in the Plan and
assign your beneficiary(s).
Once a Member of the Plan, all changes to Member information
or dependents should be made by completing a Group
Insurance Change Card.
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Information Needed to Complete the Form
Your personal Member information is needed to complete the form, including the
dates of birth for all eligible dependents, and the policy number of any other
group insurance plans that you or your dependents may also be covered under.
Please follow the instructions on the form and ensure that you have completed
the card in full. You may select a revocable beneficiary of your choice for your
Life Insurance benefits.
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Notes
If you are covered for MSP through your Plan, you must complete a separate
MSP Application For Group Enrolment Form for 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: Health
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