Canadian Insurance Plan Forms
Enrolment and Change Form
The Enrolment and Change Form is used by newly eligible employees in the insurance plan; as well as by those on the plan who are making changes to the original enrolment information. First time enrollees must complete all sections, except for the Dependant Coverage if they are not electing family Basic coverage. The Authorization section must always be completed.
All changes in your coverage can also be made on this form. This includes changing coverage, adding or deleting a dependant, changing the status of your eligible child age 21 or older to fulltime student, changing your name, changing your address, changing your beneficiary, or changing your Co-ordination of Benefits (coverage through your spouse’s employer or your fulltime student’s university coverage).
If you are enrolling later than 31 days from your date of hire (contract date) or date you first became eligible, you must complete a Statement of Health. This will be submitted to Manulife to determine if your health condition will qualify you for coverage.
Retirees may enrol by obtaining an Enrolment and Change Form from the website or contacting CSI for an enrolment form.
Optional Life Coverage – Application Form
The Optional Life Application Form is used by new, eligible employees to enrol or increase life insurance for employees and their spouses who are already on the plan.
The Optional Life Statement of Health must be completed if requesting more than $10,000 of Optional Life or increasing the current amount of Optional Life. All Optional Life requests for spouses require an Optional Life Insurance Statement of Health. Requests must be approved by ManuLife to qualify for this coverage. If requesting just $10,000 of Optional Life within 31 days of the date of hire, only the application is needed.
Critical Illness Coverage – Application Form
The Optional Critical Illness Coverage Application Form is used by new, eligible employees to enrol in this program which supplements your coverage to reduce the potentially devastating impact that 22 covered conditions may cause. Use this enrolment form if you are applying for $25,000 or less for you and/or your spouse. You may also apply for $5,000 of coverage for your child(ren).
If you are enrolling for amounts greater than $25,000, or if you are enrolling later than 30 days from your date of hire (contract date) or date you first became eligible, you must complete a Manulife Group Benefits Evidence of Insurability Form. This will be submitted to Manulife to determine if your health condition will qualify you for the coverage.
Claim Forms
The following forms are to be used when submitting health and dental claims to Manulife: Health Care Claim Form
Dental Claim Form
Manulife must be notified of address changes for health and dental claims.
Work Stoppage Form
Insurance may continue during a leave of absence upon approval from CSI and/or Manulife. The Work Stoppage Form must be completed by an authorized person at your school. Details about coverage during a leave of absence is outlined in CSI’s Update 310.
Short Term Disability Application Form
The following forms are used to apply for Short Term Disability and must be completed after a disability has begun:
Application of Temporary Disability Benefits Form
Part I is completed by the employee
Part II is completed by the employer
Certification of Disability Form
Part I is completed by the employee
Part II is completed by the attending physician
Long Term Disability Application Forms
CSI will contact any person who must complete Long Term Disability forms.
Co-op Student Insurance Registration Form
The Co-op Student Insurance Registration Form is used to enrol high school students who are involved in a co-op arrangement. It can also be used for university or college students during their practicum.
International Student Insurance Enrolment Form
The International Student Insurance Enrolment Form is used to enrol international students for coverage while they are living in Canada and attending school. See Update #305.
Mail completed registration forms with one cheque for the total to:
CSI Canada Insurance Plan and Trust Fund
Christian Schools International
3350 East Paris Ave. SE
Grand Rapids, MI 49512-3054
USA
Employer Work Information Form
The Employer Work Information Form is used to assist Manulife Financial in the adjudication of a Short Term Disability Claim. This form should be completed ONLY when requested by the CSI Canada Insurance office.
