Major Medical Plan

Group Health Insurance Plan

Membership Enrollment Form

PSCU MEMBER ACCOUNT NUMBER *

Please contact us if you don't have your member account number

LAST NAME *

FIRST NAME *

DATE OF BIRTH

SEX

MALE FEMALE

HOME TEL

CELL TEL

EMAIL *

Beneficiary Data

NAME OF BENEFICIARY

RELATIONSHIP TO MEMBER

BENEFICIARY DATE OF BIRTH

Dependents

Applicant’s Occupation *

Applicant’s Earnings *

How are Earnings Payable? *

Hourly Weekly Monthly Annually

Date Employed

Date Confirmed

Effective Date

Amount of Life Insurance *

Amount of AD&D Insurance *

Health Insurance

Yes No

Do you wish to cover your dependents

Yes No

SPOUSE

Spouse Name

Gender

Male Female

Date of Birth

Relationship

Effective date of coverage

CHILD 1

Child Name

Gender

Male Female

Date of Birth

Relationship

Effective date of coverage

CHILD 2

Child Name

Gender

Male Female

Date of Birth

Relationship

Effective date of coverage

CHILD 3

Child Name

Gender

Male Female

Date of Birth

Relationship

Effective date of coverage

CHILD 4

Child Name

Gender

Male Female

Date of Birth

Relationship

Effective date of coverage

Kindly attach and indicate the type of evidence for the following dependents, e.g.

Common-Law Certificate (Common-Law Spouse)
Student Certificate (Student aged between 19-23 years).

Common-Law Certificate

Browse

Student Certificate

Browse

Please submit your ACH information

Member name(s): *

Email Address: *

Cellphone: *

Home Telephone:

Work Telephone:

Name on Bank Account: *

Type of Account: *

Chequing Savings

Choose your Bank:

Bank Account Number: *

Bank Branch: *

Amount: *

Method of Payment

Please enter the details for your preferred method of payment

Method of Payment

Standing Order Salary Deduction Cash / Cheque

Plan

Amount Paid

Date of Paid

Date of Joined PSCU

Disclaimer

I HEREBY apply for insurance under Policyholder’s Group Plan and Authorize the deduction from my pay (if applicable) of any contribution I must make towards the cost of these or any future benefits. I also agree to produce evidence of age if required. If any beneficiary named above dies before me the interests of such beneficiary shall unless otherwise provided above accrue to the surviving beneficiaries or beneficiary or if none of my estate. I reserve the right to change any beneficiary named above.

Group Health Insurance Plan

Beneficiary Data

Dependents

Please submit your ACH information

Method of Payment

Disclaimer

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