"Slwop Group Insurance Continuation Form" - Newfoundland and Labrador, Canada

ADVERTISEMENT
ADVERTISEMENT

Download "Slwop Group Insurance Continuation Form" - Newfoundland and Labrador, Canada

Download PDF

Fill PDF online

Rate (4.6 / 5) 34 votes
Executive Council
Human Resource Secretariat
Pensions & Insurance Administration
SLWOP Group Insurance Continuation Form
Please submit this form to the Insurance Division, Department of Finance thirty (30) days prior to
commencing leave. Failure to submit may result in cancellation of group insurance coverage.
Name:
EMPLID:
Department:
Telephone:
Mailing Address:
Postal Code:
THIS IS NOT APPLICABLE TO RETIREES. Continuation of the Group Insurance Program is not offered if
self-employed or working with another employer even if on approved leave to do so. Your only “option” is
to convert your coverage over to a private policy with Great West Life within thirty-one (31) days after
termination.
 YES
 NO
I WISH TO REMAIN IN THE GROUP INSURANCE PLAN:
Leave Start Date: __________________ Expected Date of Return: ___________________
Please tick which category applies:
 Seasonal Layoff
 Special Leave without Pay
 Special Leave Without Pay -Extended Sick Leave (Have you applied for LTD or Waiver of Premium benefit?)
 Education Leave
 Maternity Leave
Please indicate:  Option A or  Option B
FOR MATERNITY LEAVE ONLY:
Option A:
I wish to continue payment of my share of the Group Insurance premiums for the period of leave
applicable (max. 18 months) with monthly post-dated cheques for period of leave. Cheques
must be made payable to: Newfoundland Exchequer Account/Group Insurance.
Option B:
I wish to have my share of the Group Insurance premiums recovered from my salary cheques when
.
I return to work for the period of leave applicable
OTHER IMPORTANT FACTS YOU SHOULD KNOW
Long Term Disability can only be continued while on Maternity Leave/Sick Leave.
If you elect to cancel Dental benefits while on leave you will have to re-apply for Dental coverage upon
return to work, and the employee and each dependent will be restricted to $100.00 for the first 12 months.
Long term disability and/or Waiver of Premium must be applied for within 4 months but no later
than 10 months from last day of work.
Employer does not match benefit premiums while on Special Leave Without Pay (only maternity leave).
Benefits can only be continued for 18 months following the approved leave of absence/ maternity/ sick
leave, etc.
_____________________________________
Employee/Survivor Signature
Date
Executive Council
Human Resource Secretariat
Pensions & Insurance Administration
SLWOP Group Insurance Continuation Form
Please submit this form to the Insurance Division, Department of Finance thirty (30) days prior to
commencing leave. Failure to submit may result in cancellation of group insurance coverage.
Name:
EMPLID:
Department:
Telephone:
Mailing Address:
Postal Code:
THIS IS NOT APPLICABLE TO RETIREES. Continuation of the Group Insurance Program is not offered if
self-employed or working with another employer even if on approved leave to do so. Your only “option” is
to convert your coverage over to a private policy with Great West Life within thirty-one (31) days after
termination.
 YES
 NO
I WISH TO REMAIN IN THE GROUP INSURANCE PLAN:
Leave Start Date: __________________ Expected Date of Return: ___________________
Please tick which category applies:
 Seasonal Layoff
 Special Leave without Pay
 Special Leave Without Pay -Extended Sick Leave (Have you applied for LTD or Waiver of Premium benefit?)
 Education Leave
 Maternity Leave
Please indicate:  Option A or  Option B
FOR MATERNITY LEAVE ONLY:
Option A:
I wish to continue payment of my share of the Group Insurance premiums for the period of leave
applicable (max. 18 months) with monthly post-dated cheques for period of leave. Cheques
must be made payable to: Newfoundland Exchequer Account/Group Insurance.
Option B:
I wish to have my share of the Group Insurance premiums recovered from my salary cheques when
.
I return to work for the period of leave applicable
OTHER IMPORTANT FACTS YOU SHOULD KNOW
Long Term Disability can only be continued while on Maternity Leave/Sick Leave.
If you elect to cancel Dental benefits while on leave you will have to re-apply for Dental coverage upon
return to work, and the employee and each dependent will be restricted to $100.00 for the first 12 months.
Long term disability and/or Waiver of Premium must be applied for within 4 months but no later
than 10 months from last day of work.
Employer does not match benefit premiums while on Special Leave Without Pay (only maternity leave).
Benefits can only be continued for 18 months following the approved leave of absence/ maternity/ sick
leave, etc.
_____________________________________
Employee/Survivor Signature
Date