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Plan Administrator's Statement

* required field

Please fill out all required(*) fields

Employer Identification

* Name of Employer:

* Plan Number:

* Division Number:

Member Identification

Employee ID Number:

* First Name:

Middle Initial:

* Last Name:

* Date of Birth:

* Address:

* City/Town:

* Province:

* Postal Code:

* Primary Phone Number:

( ) - Second three digits Last four digits

Alternate Phone Number:

( ) - Second three digits Last four digits

Employment Information

* Date of Employment:

* Current Employment Status:

Full-TimePart-Time

Number of hours per week:

Approved leave of absence (LOA)

from:

to:

approved leave

Full-TimePart-Time

Percentage:

Type of Leave:

MedicalPersonalMaternityOther

Percentage at which LTD premiums were maintained during LOA:

* Date member last worked on a regular basis before work absence began:

If member returned to work, indicate date returned:

member returned to work

Full-TimePart-Time

Percentage:

* Member's job title or position as of last day worked:

Occupation:

Elementary Teacher
Secondary Teacher
Clerical/Administration
Early Childhood Educator
Tradesperson
Educational Assistant
Other

Affiliation:

ETFO
OECTA
OSSTF
OSSTF education workers
CUPE/OPSEU
Other

If applicable, member's specific assignment as of last day worked

Grade(s):

Subject(s):

Standard number of working days based on the member's occupation:

Earnings and Benefit Information

* Annual Earnings: $

Date next salary increase is due:

Personal tax exemption code:

Code 1Other

* Original effective date of LTD coverage:

* Has coverage been continuous?:

YesNo

Effective date of most recent flex plan option change (if applicable):

Flex plan option elected by the member (if applicable):

* Number of sick leave credits remaining as of the date last worked:

Date sick leave credits will expire (paid up to and including):

If the last sick leave credit is a partial credit, please indicate at what percentage:

* Is the member eligible for pension contribution?:

YesNo

If yes, is it for:

OTPPBOMERSOther

Workplace Safety & Insurance Board (WSIB):

YesNo

Is this absence due to a workplace injury or illness?:

YesNo

* Has the member applied for benefits from WSIB?:

YesNo

WSIB claim number:

If approved, date benefits commenced:

Ceased:

Appealed:

What is the weekly benefit amount?:

What type of award?:

Is the WSIB award being topped up by the employer?:

YesNo

If yes, what percentage of regular pay is the employee being topped up to?:

Waiver of Group Life Premium:

YesNo

This section should only be completed if the member has Waiver of Group Life Premium coverage with OTIP. If coverage has been obtained elsewhere, the member should apply for a waiver with that insurer.

Plan Number:

Division Number:

* Original effective date of life coverage:

* Has coverage been continuous?:

YesNo

* Waiver of Premium benefits claimed

Basic Life

Optional Life

Optional Spousal Life

Dependant Life

Basic AD&D

Optional AD&D

Please fax a copy of the member's enrolment for group insurance coverage to 1-877-205-6847.

Other Information

Please provide any additional information that should be considered in assessing this member's claim:

Authorization of Plan Administrator

As the Plan Administrator, I certify that the information I have provided in the Plan Administrator's Statement (PAS), and any further verbal or written statement provided by me in the future concerning this claim, is true and complete to the best of my knowledge. I understand that the information in the PAS will be kept in a benefits file relating to this claim and might be accessible by third parties to whom authorized access has been granted. I acknowledge and agree that by submitting this PAS, I consent to the unedited disclosure of any information contained herein to the Trustees of the Ontario Teachers Insurance Plan and OTIP/RAEO Benefits Incorporated (“OTIP”).

I further understand and agree that the typed version of my name in the signature section shall be binding on all parties, including myself, as if that typed name was my original handwritten signature.

* Name of Authorized Individual:

* Title:

* Email:

If you have any questions, please contact your OTIP Group Life and Disability Claims representative at 1-800-267-6847.