PWGSC-TPSGC 2027-1 - Long-term Disability Insurance - Public Service Management Insurance Plan

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Protected "B" when completed

Long-term Disability Insurance - Public Service Management Insurance Plan

For Departmental Use Only Part 1

To Be Completed by the Applicant (Please Print)

Declaration: I hereby apply for Long-term Disability Insurance under the Public Service Management Insurance Plan. I understand that, provided my application is accepted by the insurer, this application cannot be revoked and I will remain a member of the disability plan until reaching age 65 or ceasing to be employed in an eligible position, whichever is earlier. I authorize the appropriate pay agency to deduct from my pay the necessary premiums. I understand that the commencement of deductions does not indicate an acceptance of my application and that, if my application is declined all amounts deducted will be refunded to me.

For Departmental Use Only Part 2

Employee Status:

Employee Status

I certify that the above-named employee was on strength on August 31, 1982, or immediately prior to the date of designation of the agency and is eligible for coverage as an optional member.

LTD - PSMIP

Receipt of Application Card or New Application Request

PWGSC-TPSGC 2027-1 (12/1998)