First Nations Insurance

A new employee of a participating employer must complete this form upon becoming eligible to participate in their group insurance plan. A separate application must be completed for each class of employment. If an employee takes a leave of absence, the employee must complete a new application upon returning. This form can be used for subsequent changes to an employee’s personal information such as name change, marital status change, dependent status or if the employee wishes to make changes to beneficiary designation(s) or trustee designation(s). Any beneficiary/trustee designations require the employee signature, date, as well as a witness signature, other than a named beneficiary. DO NOT use whiteout in Section C of this form. If the employee’s spouse has an Extended Health and/or Dental and/or Vision plan equal to or better than their employer plan, they can opt out of the applicable benefit. Subsequently, if the employee’s spouse terminates employment with their employer and no longer have EH/D/V benefits, the employee can opt back in to member’s EH/V/D plan within 31 days of their spouse’s termination. The plan administrator can use this form to report salary changes, transfers between divisions (if they have more than one division) and terminations.

Plan Administrator must complete this form and provide a copy to Plan Member and First Nations Insurance Services or Sun Life.

If Plan Member wishes to apply for additional Voluntary Accidental Death & Dismemberment benefits, plan member must complete, sign and date this application and return form to First Nations Insurance Services’ office for processing. Contact your plan administrator or FNIS for current rates.

If Plan Member wishes to apply for additional life insurance benefits, Plan Member must check Optional Life – Member under the Benefits Requested section and complete all information pertaining to the member on this form, sign it and return it to First Nations Insurance Services’ office for processing. Please contact your plan administrator or FNIS for rate bands.

If Plan Member wishes to make changes to beneficiary/trustee designation(s), the Plan Member must complete information pertaining to Employee Optional Life benefits on this form, sign it and return it to First Nations Insurance Services’ office for processing.

Plan administrator must complete this form and provide it to the employee. If the employee wishes to convert they must complete an application and forward it along with this Conversion Notice to RBC Life Insurance Company.

Plan administrator must complete this form and provide it to the employee. If the employee wishes to convert they must complete an application and forward it along with this Conversion Notice to RBC Life Insurance Company.