GREAT WEST LIFE
APPLICATION FOR GROUP COVERAGE INSTRUCTION SHEET
These are instructions to help you fill in your application for Group Insurance (green form). Complete the information on the application as listed below. You will apply for Basic Life, Accidental Death and Dismemberment, Long Term Disability, Medical and Dental Coverage.
NOTE: It is important that all information below is completed to avoid delay in the processing of your application. If you need assistance in completing your forms, please contact your Benefits Coordinator at The Western District Office.
Please complete:
Section 1 – Plan Sponsor Section – You may wish to fill this section out together with your church administrator.
Plan member ID *Leave blank, this will be assigned to you upon submission of your forms.
Eligible date of employment *The date you began full-time employ within The Western Canadian District.
Effective date of coverage *The date three months from your eligible date of employment. If this waiting period is to be waived, you need to provide approval in writing from your place of employ.
Occupation *Your position or job title (i.e. senior pastor, associate pastor, secretary, custodian…)
Earnings *Please submit the amount of your annual salary (including housing allowance) – if you are not sure of the amount, please contact your accounting department or treasurer. This amount needs to be correct because it will be used to figure out your Basic Life, AD&D and LTD.
Section 2 – Plan Member Information
Plan member name *Employee’s name
Gender
Date of birth
Mailing address *Employee’s home mailing address
Do you have a spouse?
Do you have dependants?
How many dependants? *Remember, this includes your spouse.
Section 3 – Refusal of benefits
*Only fill this out if you have coverage through your spouse’s employer and you do not wish to have coverage for either medical and/or dental.
Section 4 – Beneficiary Designation
Beneficiary’s name(s) *Note you can have more than one beneficiary – also if the beneficiary is under the age of majority (18 in Alberta), you need to fill out a trustee appointment form.
*Also mark if you wish your beneficiary to be revocable (can be changed) or irrevocable (cannot be changed).
Section 5 – Dependant Information
Spouse information *Including date of birth
Group benefits of spouse’s employer *This section must be completed even if there is no other coverage. If no other coverage is in place, select ‘none’.
Dependant information *Include name, date of birth, gender, full-time student, or disabled
Section 6 – Privacy
*Please be sure to read this section carefully.
Final Section – Authorizations and Declarations
*Please sign and date the form. Your application can not be processed without your signature.
BANKING INFORMATION SHEET – (Yellow Form)
If you wish to have your claim refunds deposited directly into your bank account, please fill out this form. If you do not want to provide this information now but wish to select this option in the future, you may do so at www.greatwestlife.com once you have signed up as a plan member.
Section 1 *Plan member name, plan member ID (leave blank), name of financial institution, transit number, institution number and account number.
Section 2 *Sign and date.
WHAT HAPPENS NEXT?
Please promptly mail these form(s) to The Western District Office.
The Benefits Coordinator with The Western District Office will process your form and apply to Great West Life for your benefits cards.
Once approved, you will be sent out your member information and benefits booklet with details about your coverage. It is recommended that once you receive this information, that you set up a member profile on www.greatwestlife.com to enable you to manage your benefits information 24 hours a day.
Of course, the Benefits Coordinator at The Western District Office is also available to assist you with your benefits needs. Please call anytime for assistance.