PWGSC-TPSGC 2027 - 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

IAN

Superannuation No.

Department No.

Paylist No.

Date received (Y-M-D)

Init.

To Be Completed by the Applicant (Please Print)

Name and Initials

Surname

Date of Birth (YYYYMMDD)

Address: Street and Number

City or Town

Province

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.

Signature of Plan Member Date (Y-M-D)

Signature

For Departmental Use Only Part 2

I certify that the above-named employee was a PSMIP member on October 31, 1970 or was eligible to apply for disability insurance on October 31, 1970 or on the effective date of the designation of the agency.

Date on which the employee
was taken on strength in the public service (Y-M-D)

Deduction to Commence
(Y-M-D)

Date

Signature (Personnel Officer)

Department or Agency

Address

Telephone Number

LTD - PSMIP

Name and Address

IANLong Term Disability

Paylist No.Long Term Disability

Receipt of Application Card or New Application Request

1. This acknowledges receipt of your application card for Long-term Disability Insurance under the Public Service Management Insurance Plan on

Signature of LTD Date (Y-M-D)

2. Please submit a new application with a Declaration of Health.

DateSignature of Personnel Officer

Personnel Officerrequest to submit a new application

PWGSC-TPSGC 2027 (12/2002)