Pre-Authorized Payment Form
Submit this form with a void cheque for automatic withdrawal of monthly invoices.
Your monthly benefits plan contributions can be paid through automatic withdrawal. Complete this form and submit it with a void company cheque to The Benefits Trust to set up this convenient process.
Submit the signed original form within 31 days of eligibility.
Before the end of their waiting period, have each new employee complete the first page of the enrollment form. Complete the second page of the enrollment form with their employment details. Submit the signed and dated original form to our office.
It is very important to enroll new employees within 31 days of the end of their waiting period, to ensure they will not be a late entrant. Late entrants may be required to submit medical evidence of insurability, and could be declined for coverage.
Direct Deposit Authorization Form
Submit this form with a void cheque.
To set up direct deposit of claims payments into their bank account, employees should submit this form with a void cheque to The Benefits Trust. An Explanation of Benefits will still be mailed to the home address we have on file for each employee, for their records.
Change of Record
Employees can use this form to change their coverage or information.
Does an employee need to add or remove a dependent? Change their coverage to Single, Family, or Waived? Advise us of a new address when they move? Change their beneficiary? All of these kinds of changes can be made with this form.
Termination / Rehire Form
Submit this form to remove an employee from the plan, or rehire a terminated employee.
Submit this form when an individual’s employment ends, or when they are no longer eligible for benefits coverage. Complete the Extension of Benefits section if benefits are being extended for a period of time, for example as part of a severance package.
Complete the Rehire section if a recently terminated employee is being rehired, and should be added back in to the benefits plan.
Over Age Dependent
This form must be submitted every school year for overage dependents still in school.
This form must be filled out and submitted every school year to confirm that an overage dependent is attending school full time, to be eligible for benefits coverage. This form should also be submitted for an overage, disabled dependent whose disability began prior to reaching the maximum age for eligible dependents. Check the benefits booklet or contact The Benefits Trust for the definition of eligible overage dependent.
Declaration Appointing Trustee
Submit this form for a life insurance beneficiary under age 18.
If your plan includes Life Insurance coverage, employees must appoint a beneficiary (the person or organization that would receive the life insurance settlement). If an employee appoints a beneficiary who is under age 18, they must appoint a Trustee by filling out and submitting this form.
Medical and Drug Expenses Claim
For Prescription Drugs, Vision Care, Medical Appliances, Paramedical Services, etc.
Employees should use this form to claim Prescription Drugs, Vision Care, Paramedical Services like Physiotherapy or Chiropractic, Medical Appliances like Orthotics or a Blood Pressure Monitor, and other Medical expenses.
Expenses for more than one person can be included on the same form.
Employees would use this form if their dental office does not provide its own form.
Dental offices may provide a detailed dental claim form printed directly from their system, which can be submitted instead of completing this form. Many dental offices will also submit electronically, in which case employees do not need to submit a form at all.Employees can use this form if their dental office asks for a claim form from the benefits provider.
A separate form should be submitted for each person’s dental expenses.
Short Term Disability Claim
This form should be submitted soon as possible after the employee stops working.
An employee should submit the Accident & Sickness Claim Form as soon as possible after an illness or injury, so that their claim can be evaluated. We recommended an employee checks that their doctor has fully completed their section to avoid any delays. During the course of their claim, a Supplemental Disability Report
may be required periodically.