Form M7306 "Student Declaration Form Over the Age of 21 or Under 25 Who Are Full-Time Students" - Newfoundland and Labrador, Canada

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Download Form M7306 "Student Declaration Form Over the Age of 21 or Under 25 Who Are Full-Time Students" - Newfoundland and Labrador, Canada

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Government of Newfoundland and Labrador
HRS Service Centre and Corporate Service Delivery
STUDENT DECLARATION FORM
OVER THE AGE OF 21 OR UNDER 25
WHO ARE FULL-TIME STUDENTS
Declaration for the period commencing September 1,
IDENTIFICATION OF MEMBER
Name of Group
Government of Newfoundland and Labrador
Policy Number
168074
Employer
Plan Member Name
Member ID #
Division No. (office use only)
IDENTIFICATION OF DEPENDANT(S)
LAST NAME
FIRST NAME
DATE OF BIRTH
NAME OF EDUCATIONAL
FULL-TIME
ENROLMENT
INSTITUTION
STUDENT
DATE
yyyy / mm / dd
yyyy / mm / dd
Yes
No
yyyy / mm / dd
yyyy / mm / dd
Yes
No
yyyy / mm / dd
yyyy / mm / dd
Yes
No
yyyy / mm / dd
yyyy / mm / dd
Yes
No
DECLARATION
I declare that the information provided herein is complete and true. I can provide, upon request, proof of eligibility for the dependant
child(ren) listed above (birth certificate, adoption certificate, proof of school attendance).
Signature of Member:
Date:
Please return this form to the HRS Service Centre and Corporate Service Delivery Division thirty (30) days prior
to the beginning of each session. Failure to submit may result in the cancellation of group insurance coverage.
A letter of confirmation can be provided by Great-West Life, if required.
DEFINITION OF DEPENDANT CHILD FOR THE PURPOSES OF THE INSURANCE PLAN
Child means a person who is the Participant’s unmarried, natural, adopted, foster or step-child (including any child of a minor, unmarried child
provided they meet Dependant eligibility) who is dependent upon the Participant for financial support and maintenance. Such child must be:
·
Under 21 years of Age: or
·
Under 25 years of Age, attending an accredited educational institution, college or university on a full-time basis. A form will be required to be
completed each year.
·
Age 21 or over who is incapacitated for a continuous period beginning before age 21, or while a full-time student and before age 25. A child is
considered functionally impaired if they are incapable of supporting themselves due to a physical or psychiatric disorder.
Please note: A Child who is working more than 30 hours per week will not be eligible for coverage unless the Child is a full-time student
© The Great-West Life Assurance Company, all rights reserved. Any modification of this
M7306(168074)-7/17
Clear
document without the express written consent of Great-West Life is strictly prohibited.
Government of Newfoundland and Labrador
HRS Service Centre and Corporate Service Delivery
STUDENT DECLARATION FORM
OVER THE AGE OF 21 OR UNDER 25
WHO ARE FULL-TIME STUDENTS
Declaration for the period commencing September 1,
IDENTIFICATION OF MEMBER
Name of Group
Government of Newfoundland and Labrador
Policy Number
168074
Employer
Plan Member Name
Member ID #
Division No. (office use only)
IDENTIFICATION OF DEPENDANT(S)
LAST NAME
FIRST NAME
DATE OF BIRTH
NAME OF EDUCATIONAL
FULL-TIME
ENROLMENT
INSTITUTION
STUDENT
DATE
yyyy / mm / dd
yyyy / mm / dd
Yes
No
yyyy / mm / dd
yyyy / mm / dd
Yes
No
yyyy / mm / dd
yyyy / mm / dd
Yes
No
yyyy / mm / dd
yyyy / mm / dd
Yes
No
DECLARATION
I declare that the information provided herein is complete and true. I can provide, upon request, proof of eligibility for the dependant
child(ren) listed above (birth certificate, adoption certificate, proof of school attendance).
Signature of Member:
Date:
Please return this form to the HRS Service Centre and Corporate Service Delivery Division thirty (30) days prior
to the beginning of each session. Failure to submit may result in the cancellation of group insurance coverage.
A letter of confirmation can be provided by Great-West Life, if required.
DEFINITION OF DEPENDANT CHILD FOR THE PURPOSES OF THE INSURANCE PLAN
Child means a person who is the Participant’s unmarried, natural, adopted, foster or step-child (including any child of a minor, unmarried child
provided they meet Dependant eligibility) who is dependent upon the Participant for financial support and maintenance. Such child must be:
·
Under 21 years of Age: or
·
Under 25 years of Age, attending an accredited educational institution, college or university on a full-time basis. A form will be required to be
completed each year.
·
Age 21 or over who is incapacitated for a continuous period beginning before age 21, or while a full-time student and before age 25. A child is
considered functionally impaired if they are incapable of supporting themselves due to a physical or psychiatric disorder.
Please note: A Child who is working more than 30 hours per week will not be eligible for coverage unless the Child is a full-time student
© The Great-West Life Assurance Company, all rights reserved. Any modification of this
M7306(168074)-7/17
Clear
document without the express written consent of Great-West Life is strictly prohibited.