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DOCUMENT |
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Public Service Management Insurance Plan (PSMIP) -- Declaration of Health (Policy Number G68-1400) |
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PWGSC-TPSGC 2028-2 (09/2002) |
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Catalogue number: 7540-21-912-7437 |
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This form can be ordered by contacting EPRINTit directly. |
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By mail:
EPRINTit Retail Products
1165 Kenaston Street
P.O. Box 9809
Station T
Ottawa ON K1G 6S1 |
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By telephone:
Customer Service: (613) 746-4005 (National Capital Region)
Customer Service: Toll free 1 888 562-5561 (outside the National Capital Region) |
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By facsimile:
(613) 740-3114 |
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By e-mail:
dlsorderdesk@eprintit.com |
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By the Web site:
http://retailforms.sjpg.com
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PURPOSE |
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This form is completed when the employee and/or his dependants are required to submit a Declaration of Health (refer to Section 4.10.2 of the Insurance Administration Manual [IAM] ).
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PROCEDURES |
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For the procedures to follow for the completion and distribution of the form PWGSC-TPSGC 2028-2, refer to the following IAM sections: Section 4.11.3 for an initial application, Section 4.12.3 for an amendment in coverage and Section 4.14.3 for a Long-term Disability (LTD) application.
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COMPLETION INSTRUCTIONS -- REVERSE SIDE OF FORM |
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The compensation advisor completes this part of the form to provide the tombstone data necessary to identify the employee.
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INDIVIDUAL AGENCY NO. (IAN) |
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PURPOSE - to identify the employee's IAN. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS - the employee's IAN.
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EMPLOYEE SURNAME |
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PURPOSE - to identify the employee's surname. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS - the employee's surname.
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GIVEN NAMES |
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PURPOSE - to identify the employee's given names. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS - the employee's given names.
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DEPARTMENT NAME |
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PURPOSE - to identify the employee's department. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS - the name of the employee's department.
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DEPARTMENT ADDRESS |
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PURPOSE - to identify the address of the department. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS - the complete address of the department including the postal code.
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DATE OF LAST ENTRY INTO THE PUBLIC SERVICE (Y-M-D) |
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PURPOSE - to identify the employee's last date of entry into the public service. This date helps the Superannuation, Pension Transition and Client Services Sector verify if the employee is an optional member. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS - the employee's last date of entry into the public service.
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DATE OF BIRTH (Y-M-D) |
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PURPOSE - to identify the employee's date of birth. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS - the employee's date of birth.
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DATE, NAME OF COMPENSATION ADVISOR, TELEPHONE NO. AND SIGNATURE OF COMPENSATION ADVISOR |
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PURPOSE - to identify the responsible compensation advisor. |
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REQUIREMENT - mandatory. |
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Compensation Advisor |
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INSERTS the information requested in the spaces provided and signs the document.
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