Plan Administrator's Statement


Employer Identification
Member Identification
()-
()-
Employment Information

%
%

%












Earnings and Benefit Information
$


%

%
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.
Please fax a copy of the member's enrolment for group insurance coverage to 1-877-205-6847.
Other Information
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 OTIP and its Insurer.

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.
If you have any questions, please contact your OTIP Group Life and Disability Claims representative at 1-800-267-6847.
Need help?
x
How can we help?