Plan Administrator's Statement

Employer Identification

* Name of Employer

* Plan Number

* Class

Contact Name

Email address

City

Province

Postal Code

Member Identification

* First Name

Middle Initial

* Last Name

* Sex

* Date of Birth

* City/Town

* Province

* Postal Code

* Primary Phone Number

( ) -

Alternate Phone Number

( ) -

Employment Information

* Date of Employment

* Current Employment Status Full-TimePart-Time

Number of hours per week

Approved leave of absence (LOA)

Full-TimePart-Time

Percentage

Type of Leave

MedicalPersonalMaternityOther

Percentage at which LTD contributions were maintained during LOA

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

If member returned to work, indicate date returned

Full-TimePart-Time

Percentage

If there were sporadic absences, attendance records will be required dating back to when the member last worked on a regular basis.

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

Earnings and Benefit Information

Date next salary increase is due

Personal tax exemption code

Code 1Other

* Original effective date of LTD coverage

* Has coverage been continuous?

YesNo

Short-term sick leave will expire (paid up to and including)

* Is the member eligible for pension contribution?

YesNo

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

If approved, date benefits commenced

Ceased

Appealed

What is the weekly benefit amount?

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

Other Information

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

Please note: 500 word limit

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. <br></br>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 collection, use and 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

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