Change Card

Use a Group Insurance Change Form 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 Form to initially enrol in their Plan.

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.

If you are covered for MSP through your Plan, you must complete a separate MSP Group Change Form to update your MSP coverage.

Completed forms should be forwarded to your Human Resources Department.

More Information
Questions on completing the form should be directed to the Plan Administrator.