PWGSC-TPSGC 2028 - Public Service Management Insurance Plan

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Protected "B" when completed

Public Service Management Insurance Plan

Public Service Management Insurance Plan - Members Entitled to Government-Paid Coverage

1. Initial Application 2. Observation 3. Total Cancellation

*Please indicate all coverage requested when amending

For Departmental Use Only

Individual Agency Number (IAN)

Superannuation No.

Dept. No.

Paylist No.

Date received (Y-M-D)

Initials

To Be Completed by the Applicant

Name and Initials

Surname

Date of Birth (YYYYMMDD)

Sex

M F

Mailing Address

Name of Beneficiary

Relationship

I reserve the right to revoke this beneficiary appointment (for initial application only)

Yes 1
No 1

Employee coverage (I hereby apply for Basic Life Insurance and for the optional coverage indicated below):

Supplementary Life Insurance (Declaration of Health [PWGSC-TPSGC 2028-2] required)

Yes 2
No 2

Accidental Death and Dismemberment Insurance - In units of $25,000 up to a maximum of 10 (insert the number of units in the "yes" box)

Yes 3 Yes box $

No 3

Dependant's Insurance:

Spouse and Children
Children Only

1 - Spouse and Children
2 - Children Only

I am (I am not) insured under an employee organization group insurance plan. My last day of coverage is

(Y-M-D)

I authorize the appropriate Pay Agency to deduct from my pay the necessary premiums. This authorization shall continue until revoked by me in writing.

I hereby cancel my insurance.

Date (Y-M-D)

Signature

For Departmental Use Only part 2

Date on which the employee was taken on strength in the Public Service

(Y-M-D)

Date on which the employee became eligible to apply for PSMIP

(Y-M-D)

Date (Y-M-D) 2

Signature 2

Location

Department or Agency

Telephone Number

Complete Address of Department or Agency

PSMIP

Name and Address

IAN 2

Paylist Number 2

Public Service Management Insurance Plan

1. This acknowledges receipt of your application card on:

Date (Y-M-D) 3

(Y-M-D)

2. Please submit a Declaration of Health (PWGSC-TPSGC 2028-2).

Date (Y-M-D) 4

Signature Personnel Officer

PWGSC-TPSGC 2028-7 (09/1995)