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Address (number, street, city, province, postal code)
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Plan member signature: Date (mm/dd/yy):
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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Public Service Dental Care Dependant Information Form
You must complete and submit a Dependant Information form for any of the following change: dependant name changes, dependant date of birth change, removing/
terminating a dependant, adding a spouse, adding a child (including adoption or guardian appointment) or student status change.
Plan members must write to the Board of Management of the Public Service to cover a sibling, sibling’s child or grandchild. For more details, please see the
Public Service Dental Care Plan Member booklet
PLEASE INDICATE THE APPLICABLE DENTAL PLAN NUMBER:
55555 - National Joint Council 55666 - Public Service Alliance of Canada 55777 - Canadian Forces Dependants 55888 - Royal Canadian Mounted Police
PLAN MEMBER INFORMATION
DEPENDANT INFORMATION – SPOUSE
Type of Change
Add Change Remove
Last Name First Name
Date of
Birth
(YYYY/MM/DD)
If adding a spouse,
confirm if legal
marriage or
common law
Confirm date of
marriage or date
you started living
together
(YYYY/MM/DD)
If removing a
spouse, confirm
date of divorce or
separation
(YYYY/MM/DD)
Is this person eligible for benets from any other plan, either personally or as someone else’s dependant? YES NO
For 55777 only, has your relationship been established with qr & o article 1.075? YES NO
DEPENDANT INFORMATION – CHILD
Type of Change
Add Change Remove
Last Name First Name
Date of
Birth
(YYYY/MM/DD)
Date of
Change
(YYYY/MM/DD)
If child over 21 years,
full-time student
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Is this person eligible for benets from any other plan, either personally or as someone else’s dependant? YES NO
PRIVACY
This section explains Canada Life’s commitment to privacy.
At The Canada Life Assurance Company, we recognize and respect the importance of privacy. When you apply for coverage, we establish a confidential file
that contains
your personal information. This file is kept in the offices of Canada Life or the offices of an organization authorized by Canada Life. You may exercise
certain rights of access and rectification with respect to the personal information in your file by sending a request in writing to Canada Life. Canada Life may use
service providers located within or outside Canada. We limit access to personal information in your file to Canada Life staff or persons authorized by Canada Life
who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law. Your personal information may be subject to
disclosure to those authorized under applicable law within or outside Canada. Personal information that we collect will be used for the purposes of determining your
eligibility for coverage and administering the group benefits plan. This includes investigating and assessing claims, and creating and maintaining records concerning
our relationship. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to
service providers), write to Canada Life’s Chief Compliance Officer or refer to www.canadalife.com.
AUTHORIZATIONS AND DECLARATIONS
This section must be signed and dated in INK by the employee.
I hereby, send you the information on coverage for my spouse and/or unmarried dependent children under the group benefits plan and I confirm that I am
authorized to act on their behalf.
I have read and understand and agree with the contents of the section on this form entitled “Privacy”.
I authorize:
Canada Life, 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 Canada Life or the above to exchange personal information, when relevant and
necessary to determine my eligibility for coverage and to administer the plan.
I agree that a photocopy or electronic copy of the Authorizations and Declarations section is as valid as the original.
I certify that the information given is true, correct and complete to the best of my knowledge.
For Québec applicants: I request that this form be in English.
Je demande que ce formulaire me soit remis en anglais.
MAIL OR EMAIL THIS FORM TO:
For Canadian residents except residents of Quebec:
Health and Dental Claims Centre
P.O. Box 6025, Station Main
Winnipeg MB
Canada
R3C 3C7
Email: [email protected]
For Quebec residents, other than the National Capital Region:
Montreal Benet Payments
Place Bonaventure
800 de la Gauchetière Street West Suite 5800
Montreal QC
Canada
H5A 1B9
Email: [email protected]
For employees residing outside Canada
Canada Life Health and Dental Benets
Foreign Benets Payments
P.O. Box 6000
Winnipeg MB
Canada
R3C 3A5
Email: [email protected]
M4749(PSDCP)-8/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
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