Public Works and Government Services Canada
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IAM 4.27.2028.5

Section: FORMS COMPLETION

Subsection: APPLICATION - LIFE PORTION (PART-TIME EMPLOYEES)

DOCUMENT

Public Service Management Insurance Plan

Part-time Employee Only

PWGSC-TPSGC 2028-5

Catalogue number: 7540-21-890-0444.

PURPOSE

This form is completed when a part-time employee wishes to:

  1. apply for Basic Life and, if applicable, for Supplementary Life, Accidental Death and Dismemberment and Dependants'Insurance; or,
  2. amend their coverage under the Plan; or,
  3. cancel their coverage under their Plan.

PROCEDURES

The procedures to follow for the completion and distribution of the form PWGSC-TPSGC 2028-5 are contained in the following sections:

  1. section IAM 4.11.3 for employees joining the Plan;
  2. section IAM 4.12.3 for employees amending their coverage under the Plan;
  3. section IAM 4.13.2 for employees cancelling their coverage under the Plan.

COMPLETION INSTRUCTIONS BLOCKS 1, 2 OR 3

PURPOSE - to determine what action is requested by the employee.

REQUIREMENT - mandatory.

Personnel Officer

CHECK OFF

  • block 1 for an initial application
  • block 2 for a change in coverage
  • block 3 for a total cancellation.

COMPLETION INSTRUCTIONS - FOR AN INITIAL APPLICATION

The following instructions will describe how to complete the PWGSC-TPSGC 2028-5, when an employee is joining the Plan.

BLOCK 1 INITIAL APPLICATION

PURPOSE - to identify that the application is an initial application.

REQUIREMENT - mandatory.

Personnel Officer

CHECK OFF box 1 for an initial application.

COMPLETION INSTRUCTIONS - FOR DEPT. USE ONLY

The Personnel Officer completes this section to provide the Superannuation Directorate with the administrative details required to process the application.

BLOCK 4 SIN

PURPOSE - to identify the applicant's social insurance number.

Note: The applications are filed by SIN order at the Superannuation Directorate.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the applicant's social insurance number.

SUPERANNUATION #

PURPOSE - to identify the applicant's superannuation number, if he/she was a contributor at one time.

REQUIREMENT - optional.

Personnel Officer

INSERT the applicant's superannuation number if available, or LEAVE BLANK if not available.

BLOCK 5 DEPT #

PURPOSE - to identify the applicant's department number.

REQUIREMENT - optional.

Personnel Officer

INSERT the applicant's department number

BLOCK 6 PAYLIST

PURPOSE - to identify the applicant's paylist number.

REQUIREMENT - optional.

Personnel Officer

INSERT the applicant's paylist number.

BLOCK 7 EMP. #

PURPOSE - to identify the applicant's employee number.

REQUIREMENT

  • optional for employees paid through Central Pay Office (Post Office Department)
  • not required for other employees.

Note: The employee number is the employee's social insurance number for employees paid through Pay Offices other than the Central Pay Office. The employee paid through Central Pay Office have a four digit employee number.

Personnel Officer

INSERT the employee number, if employee paid through Central Pay Office (Post Office Department), or, LEAVE BLANK if paid through other Pay Offices.

BLOCK 8 DATE RECEIVED INITIALS

PURPOSE - to determine the date on which the application was received in the Personnel Office. This block determines with blocks 16 and 18 the date on which deductions and coverage will be effective. This block also determines with block 18, if a Statement of Health is required.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the day, month and year on which the application was received in the Personnel Office and his/her initial.

COMPLETION INSTRUCTIONS - TO BE COMPLETED BY APPLICANT (part 1)

The applicant completes this section to indicate the coverage he/she desires, to name a beneficiary, to authorize deductions from pay and to provide additional administrative information to process the application.

BLOCK 9 NAME (INITIALS)

PURPOSE - to identify the participant's initials.

REQUIREMENT - mandatory.

Applicant

INSERT your initials.

BLOCK 10 (SURNAME)

PURPOSE - to identify the participant's surname.

REQUIREMENT - mandatory.

Applicant

INSERT your surname.

BLOCK 11 DATE OF BIRTH

PURPOSE - to determine the participant's age. The age is a criteria to determine the monthly premium.

REQUIREMENT - mandatory.

Applicant

INSERT the day, month, year of your birth.

BLOCK 12 SEX

PURPOSE - to identify the applicant's sex. The sex is a criteria to determine the monthly premium.

REQUIREMENT - mandatory.

Claimant

CHECK OFF the "M" box for male or "F" box for female.

MAILING ADDRESS

PURPOSE - to identify the applicant's home mailing address. The province of residence may affect the naming of a beneficiary (section IAM 4.7.3 refers).

REQUIREMENT - mandatory.

Applicant

INSERT the street number, the street, the city or town, the province of your residence and your postal code.

NAME OF BENEFICIARY

PURPOSE - to determine to whom the benefits will be payable.

REQUIREMENT - optional.

Note: If no beneficiary is named, the benefits are payable to the estate.

Applicant

INSERT the beneficiary's given name and surname.

Note: section IAM 4.7.1 should be consulted for more details on who can be named as beneficiary.

RELATIONSHIP

PURPOSE - to determine the relationship that exists between the beneficiary and the applicant.

Note: This may affect the naming of a new beneficiary for a Quebec resident (section IAM 4.7.3 refers).

REQUIREMENT - mandatory.

Applicant

INSERT the beneficiary's relationship with the applicant.

I RESERVE THE RIGHT TO...

PURPOSE - to determine if the beneficiary appointment will be revocable or irrevocable. This question only applies at this time to Quebec residents (section IAM 4.7.3 refers).

REQUIREMENT

  • mandatory for Quebec residents.
  • optional for residents of other provinces, however it is recommended that all applicants complete this block.
Applicant

CHECK OFF the "YES" box if you wish to reserve the right to revoke the appointment or, the "NO" box if you do not wish to reserve the right to revoke the appointment.

The applicant completes these blocks to indicate the coverage he/she wishes.

BLOCK 13 SUPPLEMENTARY

PURPOSE - to determine if the applicant wishes to be insured under the Supplementary Life Insurance.

REQUIREMENT - mandatory.

Applicant

CHECK OFF the "YES" box if you wish the Supplementary Life Insurance or the "NO" box if you do not wish this Insurance.

BLOCKS 14 AD&D

PURPOSE - to determine if the applicant wishes to be insured under the Accidental Death and Dismemberment Insurance.

REQUIREMENT - mandatory.

Applicant

CHECK OFF the "NO" box if you do not want this coverage, or CHECK OFF in the "YES" box the number of units of AD&D you wish.

Note: The maximum number of units a part-time employee may select depends on the number of his/her assigned hours (section IAM 4.5.2 refers).

BLOCK 15 DEPENDANT(S) INSURANCE

PURPOSE - to determine if the applicant wishes to insure his/her dependant(s). And, if he/she wishes the insurance, to determine for whom, i.e. his/her spouse and, if applicable, his/her child(ren) or his/her child(ren) only.

REQUIREMENT - mandatory.

Applicant

CHECK OFF the "YES" box in 15.1, and the "NO" box in 15.2, if you wish the coverage for your spouse and child(ren) only; or CHECK OFF the "YES" box in 15.2 and the "NO" box in 15.1, if you wish the coverage for your child(ren) only; or CHECK OFF the "NO" box in 15.1 and 15.2 if you do not wish the Dependants'Insurance.

BLOCK 16 I AM (I AM NOT) INSURED UNDER...

PURPOSE - to determine if the applicant wishes to defer his/her coverage under PSMIP until the coverage under his/her Employee Organization Group Insurance is terminated.

REQUIREMENT - optional, completed only if the applicant wishes to defer his/her PSMIP coverage.

Applicant

INSERT the day, month, year of the last day of coverage under the other group plan, or,

LEAVE BLANK if the applicant wishes his/her coverage under PSMIP to start in the normal manner (section IAM 4.11.5 refers).

I AUTHORIZE THE PAY... DATE SIGNATURE

PURPOSE - to obtain the applicant's authorization to deduct the appropriate premiums from his/her pay.

Applicant

CHECK OFF box beside statement "I authorize ." and, DATE and SIGN in the spaces provided.

COMPLETION INSTRUCTIONS - FOR DEPARTMENTAL USE ONLY (part 1)

The Personnel Officer completes this section to certify the employee's eligibility to join the Plan.

BLOCK 17 DATE EMPLOYEE TAKEN ON...

PURPOSE - to determine the date on which the employee was taken on strength.

Note: This block helps the Superannuation Directorate to verify the employee's eligibility to join the Plan.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the day, month and year of the date on which the employee was taken on strength.

BLOCK 18 DATE EMPLOYEE BECAME...

PURPOSE - to determine the date on which the employee became eligible to join the Plan.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the day, month and year of date on which the employee became eligible (section IAM 4.2.2 refers) to apply for PSMIP.

Note: Do not insert in this block the date on which deductions will start.

ASSIGNED HOURS/WEEK

PURPOSE - to identify the current number of the employee's assigned hours per week. This will determine with the equivalent full-time hours if the employee is eligible to join the Plan. It also determines the maximum units of AD&D the employee may select.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the number of assigned hours per week.

EQUIVALENT FULL-TIME...

PURPOSE - to identify the number of full-time hours per week for the employee's occupational group.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the number of full-time hours per week for the employee's occupational group.

DATE SIGNATURE

PURPOSE - to certify the employee's eligibility to join the Plan.

REQUIREMENT - mandatory.

Personnel Officer

DATE and SIGN in the spaces provided.

LOCATION

PURPOSE - to identify the employee's Personnel Office's location.

REQUIREMENT - optional.

Personnel Officer

INSERT the city where the Personnel Office is located.

DEPARTMENT OR AGENCY TELEPHONE

PURPOSE - to identify the name of the Department or Agency and the Personnel Office address and telephone number.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the name of the Department or Agency, complete address of the Personnel Office (including the postal code) and the telephone number (including the area code).

COMPLETION INSTRUCTIONS - STUB OF APPLICATION (part 1)

The Personnel Officer completes the stub of the application to acknowledge receipt of the application from the employee and/or request the employee to submit a new application or Statement of Health.

NAME AND ADDRESS

PURPOSE - to identify the applicant's name and home address.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the applicant given name and surname and his/her complete home address (street number, street, city, province and postal code).

SIN

PURPOSE - to identify the applicant's social insurance number.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the applicant's social insurance number.

PAYLIST # EMP. NO.

PURPOSE - to identify the employee's paylist and employee number.

REQUIREMENT - optional.

Personnel Officer

INSERT the applicant's paylist and employee number.

BLOCKS 1, 2 AND 3

PURPOSE - to acknowledge receipt of the application and, if applicable, request the employee to submit a Statement of Health and/or a new application.

REQUIREMENT - mandatory.

Personnel Officer

CHECK OFF block 2 and INSERT the date on which the application was received in the Personnel Office and CHECK OFF Block 1 and/or 2, if applicable.

DATE PERSONNEL OFFICER

PURPOSE - to identify the Personnel officer who processed the employee's application.

REQUIREMENT - mandatory.

Personnel Officer

DATE and SIGN in the spaces provided.

COMPLETION INSTRUCTIONS - FOR A CHANGE IN COVERAGE

Since an application to change the coverage is essentially completed the same way as an initial application the following instructions will only emphasize the differences in the completion of the form PWGSC-TPSGC 2028-5, when an employee is changing his/ her coverage.

BLOCK 2 CHANGE ID COVERAGE

PURPOSE - to identify that the application is for a change in coverage.

REQUIREMENT - mandatory.

Personnel Officer

CHECK OFF box 2 for a change in coverage.

BLOCKS 4 to 7

PURPOSE - to provide the Superannuation Directorate with the administrative details required to process the application.

REQUIREMENT - as for an initial application.

Personnel Officer

INSERT applicable information as per the instructions given for an initial application.

BLOCK 8 DATE RECEIVED INITIALS

PURPOSE - to determine the date on which the application is received in the Personnel Office. This date will determine when the amended coverage and deductions will be effective (section IAM 4.12.5 refers). This date will also be used to determine if a Statement of Health is required.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the day, month and year of date on which the application was received in the Personnel Office and your initials.

COMPLETION INSTRUCTIONS - TO BE COMPLETED BY APPLICANT (part 2)

The applicant completes this section to indicate the coverage he/she desires; to authorize the new deductions from pay and to provide administrative information required to process the application.

BLOCKS 9 to 12 AND MAILING ADDRESS

PURPOSE - to provide the Superannuation Directorate with administrative details required to process the application.

REQUIREMENT - as for an initial application.

Applicant

INSERT applicable information as per the instructions given for an initial application.

NAME OF BENEFICIARY RELATIONSHIP I reserve the right...

PURPOSE - to identify the current beneficiary.

Note: The applicant cannot change his/her beneficiary with a PWGSC-TPSGC 2028-5. The change of beneficiary card PWGSC-TPSGC 2028-1 must be completed if he/she wishes to change his/her beneficiary.

REQUIREMENT - optional.

Note: These blocks must show the same information as on the employee's previous application, or form PWGSC-TPSGC 2028-1 must be completed, if the employee wishes to change his/her beneficiary.

Applicant

INSERT the same information he/she had indicated on his/her previous application or, "PWGSC-TPSGC 2028-1" completed.

BLOCKS 13 to 15

PURPOSE - to indicate all the coverage the applicant desires.

Note: The applicant must show all the coverage he/she desires not only the coverage he/she wishes to add or delete. Only the last application is kept on the Superannuation Directorate's file.

REQUIREMENT - mandatory.

Applicant

CHECK OFF applicable box and INSERT information as per the instructions given for an initial application.

Note: If the employee is adding the Dependants'Insurance, he/she must also indicate beside "Spouse and children only" "marriage and the date of marriage" or "common-law spouse and date" or "acquire child(ren) and date" as applicable. If the application is received more than 60 days after the date on which the employee acquires new dependant(s), a Statement of Health is required for each dependant.

BLOCK 16

This block is never completed for a change in coverage.

I AUTHORIZE THE PAY... DATE SIGNATURE

PURPOSE - to obtain the applicant's authorization to deduct the appropriate premiums from his/her pay.

REQUIREMENT - mandatory.

Applicant

CHECK OFF the applicable box and DATE and SIGN in the spaces provided.

COMPLETION INSTRUCTIONS - FOR DEPARTMENTAL USE

PURPOSE - to provide the Superannuation Directorate with administrative details to process the application.

REQUIREMENT - mandatory.

Note: Only the last application is kept on the Superannuation Directorate's file. Therefore, this information is required for record purposes.

Personnel Officer

INSERT the applicable information as per the instructions given for an initial application.

COMPLETION INSTRUCTIONS - STUB OF APPLICATION (part 2)

PURPOSE - to acknowledge receipt of the application, request the submission of a new application or the submission of a Statement of Health.

REQUIREMENT - as per instructions given for an initial application.

Personnel Officer

INSERT applicable information as per the instructions given for an initial application.

COMPLETION INSTRUCTIONS - FOR A TOTAL CANCELLATION

The following instructions will describe how to complete the PWGSC-TPSGC 2028-5 when an employee is requesting the total cancellation of his/her coverage.

BLOCK 3 TOTAL CANCELLATION

PURPOSE - to identify that the application is for a total cancellation of coverage.

REQUIREMENT - mandatory.

CHECK OFF box 3 for a total cancellation.

COMPLETION INSTRUCTIONS - FOR DEPARTMENTAL USE ONLY BLOCKS 4 TO 7

PURPOSE - to provide the Superannuation Directorate with administrative details required to process the application.

REQUIREMENT - as for an initial application.

Personnel Officer

INSERT applicable information as per the instructions given for an initial application.

BLOCK 8 DATE RECEIVED INITIALS

PURPOSE - to determine the date on which the application is Received in the Personnel Office. This date will determine when the cancellation of coverage and deductions are effective (section IAM 4.13.3 refers).

REQUIREMENT - mandatory.

Personnel Officer

INSERT the day, month and year of date on which the application was received in the Personnel Office.

COMPLETION INSTRUCTIONS - TO BE COMPLETED BY APPLICANT (part 3)

The employee completes this section to authorize the cancellation of his/her insurance.

BLOCKS 9 and 10 - NAME AND SURNAME

PURPOSE - to identify the employee's initials and surname.

REQUIREMENT - mandatory.

Applicant

INSERT your initials and surname.

BLOCKS 11 TO BLOCKS 16

Blocks 11 to 16, the mailing address and the name of the beneficiary are never completed for a cancellation in coverage.

I HEREBY CANCEL...DATE SIGNATURE

PURPOSE - to obtain the employee's authorization to cancel his/her insurance.

REQUIREMENT - mandatory.

CHECK OFF the box "I hereby cancel my insurance" and, DATE and SIGN in the spaces provided.

COMPLETION INSTRUCTIONS - FOR DEPARTMENTAL USE ONLY (part 2)

The Personnel Officer completes this block to certify the information given and to provide the Superannuation Directorate with their address and telephone number.

BLOCKS 17 AND 18

These blocks are not completed for a cancellation in coverage.

DATE SIGNATURE

PURPOSE - to certify the information given.

REQUIREMENT - mandatory.

Personnel Officer

DATE and SIGN in the spaces provided.

LOCATION DEPARTMENT TELEPHONE

PURPOSE - to provide the Superannuation Directorate with the information required to contact the Personnel Officer, if necessary.

REQUIREMENT - mandatory.

Personnel Officer

INSERT the city where the Personnel Office is located, the name of the Department or Agency, the Personnel Office's complete address (including the postal code) and the telephone number (including the area code).

COMPLETION INSTRUCTIONS - STUB OF APPLICATION (part 3)

PURPOSE - to acknowledge receipt of the application.

REQUIREMENT - as per instructions given for an initial application.

Personnel Officer

INSERT applicable information as per the instructions given for an initial application.

Last Update: November 1998