SEIU Locals 1 & 2 Benefit Trust Fund

Group Benefit Enrolment and Beneficiary Designation Form

Administrator:

Global Benefits

901 – 191 The West Mall
Toronto, ON M9C 5K8

Tel: 416-635-6000
Fax: 416-631-3064

Make sure to fill out every section of the form.

To ensure that coverage is kept up to date for you and your dependents, it is vital that you advise your Plan Administrator of any changes such as change of name, marital status, dependent status, or change of beneficiary.

Plan Member Information

Last Name:

First Name:

Initial:

Certificate #:

Note: If you are already enrolled and are registering for online use, please provide your certificate number. If you are enrolling for the first time, please leave this field empty.

Last 3 Digits of SIN:

Street Address:

Apartment, Suite, Unit, etc.:

Additional Address Information:

City:

Province:

Postal Code:

Home Phone:

Cell Phone:

Email:

Gender:

Marital Status:

Member's Date of Birth:

Date of marriage or if common law date on which cohabitation period started:

Employer:

Dependent Information

This section allows you to define who will be entitled to your Health Benefits.

Primary Beneficiary Designation

This section must be completed to designate a beneficiary for your life benefits and other benefits which may become payable under the Benefit Trust upon your death. If no beneficiary is named or the primary beneficiary predeceases you, the proceeds shall be paid to your estate.

I hereby revoke all previous Primary beneficiary designations and designate the following as beneficiary(ies). The sum of all percentages must add to 100%. You may leave the % fields blank if you wish to divide the proceeds equally among all the names listed in this section.

Contingent Beneficiary Designation

If you wish to appoint a contingent beneficiary in the event that there are no surviving primary beneficiaries at the time of your death, please complete this section. If there are no Contingent Beneficiaries at the time of my death, the proceeds shall be paid to your estate.

I hereby revoke all previous Contingent beneficiary designations and designate the following as beneficiary(ies).

Privacy

This section explains Global Benefits' commitment to privacy.

At Global Benefits we recognize and respect the importance of privacy.

Your personal information:

When you apply for coverage, we establish a confidential file that contains your personal information like your name, contact information, and products and coverage you have with us and may also include financial or health information. Your information is kept in the offices of Global Benefits or the offices of an organization authorized by Global Benefits.

Who has access to your information:

We limit access to personal information in your file to Global Benefits staff or persons authorized by Global Benefits who require it to perform their duties and to persons to whom you have granted access. Your personal information may also be subject to disclosure to public authorities or others authorized under applicable law within or outside Canada.

What your information is used for:

Personal information that we collect will be used for the purposes of determining your eligibility for products, services or coverage for which you apply, providing, administering or servicing products or coverage you have with us, and for Global Benefits and its affiliates' internal data management and analytics purposes.

If you want to know more:

If you have questions about our personal information policies and practices, write to SEIU Locals 1 & 2 Benefit Trust c/o Global Benefits Chief Compliance Officer at:

SEIU Locals 1 & 2 Benefit Trust
c/o Global Benefits
901 – 191 The West Mall
Toronto, ON M9C 5K8

T: (416) 635-6000 F: (416) 631-3064
E: [email protected]

Authorizations and Declarations

This section must be signed and dated by the plan member.

I have read and understand and agree with the contents of the section on this form entitled “Privacy”.

I authorize:

Global Benefits, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators of government benefits or other benefits programs, other organizations, or service providers working with Global Benefits or the above to exchange personal information, when necessary to determine eligibility for coverage and to administer the plan.

I agree that a photocopy or electronic copy of the Authorizations and Declarations section is valid as the original.

I authorize the use of my Social Insurance Number as my Certificate Number under the group plan and as my identification number in the SEIU Locals 1 & 2 Benefit Trust Fund database.

I certify that the information given is true, correct and complete to the best of my knowledge.