Public Services and Procurement Canada
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Protected "B" when completed
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.
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.
PWGSC-TPSGC 2027 (12/2002)