Complete each of the Application for Enrolment and Beneficiary Designation forms to enrol in the Boilermakers Lodge No. 191 Benefit Plan and to enrol your dependents and assign your beneficiary(s).
Once a Member is enrolled in the Plan, all changes to Member information, dependents or beneficiaries should be made by completing the new Application for Enrolment and Beneficiary Designation form in full and submitting it to the Plan Administrator.
If you are adding a Common-Law Spouse to your benefits, the cohabitation period required is a continuous 12-month period and it will require you complete a new Benefit Plan Application for Enrolment and Beneficiary Designation form, a new Pension Plan Application for Enrolment and Beneficiary Designation form. These must be completed and signed and submitted to the Plan Administrator. Originals must be mailed. Photocopies, faxes or emails will not be accepted.
You must complete the MSP Application for Group Enrolment form if you wish to be covered for MSP under the Health & Wellness Plan.
You should complete the MSP Group Change Form if you are covered for MSP under the Health & Wellness Plan and you want to add or delete a dependent.
Information Needed to Complete the Form
Your personal Member information is needed to complete the form, including the dates of birth for all eligible dependents, and the policy number of any other group insurance plans that you or your dependents may also be covered under. Please follow the instructions on the form and ensure that you have completed the card in full.
You may select a revocable beneficiary of your choice for your Life Insurance benefits. With respect to your Pension benefits, if you have a spouse, you must designated him/her as your Pension beneficiary. If you do not have a spouse, you may select any person, or your estate, to be your Pension beneficiary. Please ensure that you complete this section of the card.
Questions on completing the form should be directed to the PLAN ADMINISTRATOR.
Completed forms should be sent to the PLAN ADMINISTRATOR.