APPLICATION FOR CONTINUATION OF BENEFITS LEAVE OF ABSENCE - WITHOUT PAY
Human Resources Department •550 University Avenue•Charlottetown•P.E.I.•C1A 4P3•902-566-0514•Fax 902-894-2895
Please return this form to Human Resources at least three (3) weeks prior to your leave. This will ensure no interruption of benefit coverage. Should this form not be returned, all benefits will terminate on the last day of active employment prior to the leave.
EMPLOYEE NAME:
POSITION: START DATE OF LEAVE: PURPOSE OF LEAVE: ARTICLE: CONTACT INFORMATION WHILE ON LEAVE ADDRESS: PHONE: EMAIL:
ID: RETURN TO WORK DATE:
LEAVING THE COUNTRY? G NO G YES IF YES, PLEASE INDICATE TO WHICH COUNTRY/COUNTRIES YOU WILL BE TRAVELING:
BENEFIT
No claims can be made under any benefits if payment of premiums is not continued during the leave of absence
COST PER PAY
INITIAL ONE
SUPPLEMENTARY HEALTH & DENTAL
$ YES NO
LONG TERM DISABILITY
On approval of Carrier (Assuming UPEI is the only employer)
$ YES NO
LIFE INSURANCE
$ YES NO
CONTINUATION OF PENSION CONTRIBUTIONS (SUBJECT TO CCRA GUIDELINES)
$ YES NO
PREMIUM PAYMENT:
PLEASE COMPLETE THE FOLLOWING PREFERENCES REGARDING CONTINUATION OF
9I
ELECT TO TERMINATE ALL BENEFIT COVERAGE AND UNDERSTAND THAT MY BENEFITS WILL
CEASE AS OF THE START DATE OF MY LEAVE. LEAVE
I AM AWARE THAT IF I INCUR ANY CLAIMS WHILE ON UPEI NOR THE INSURER WILL BE RESPONSIBLE FOR ANY LIABILITY WHILE I AM ON LEAVE. ONCE I RETURN TO WORK MY BENEFITS WILL BE REINSTATED.
EMPLOYEE SIGNATURE:
DATE:
WITNESS
DATE:
OR
9I
ELECT TO CONTINUE THE COVERAGE AS ACKNOWLEDGE ON PAGE
1, PAYMENT ARRANGEMENTS
ARE LISTED BELOW
COST TOTAL/PAY =$____________ * # OF PAYS PAYMENT OF COST G FULL PREMIUM FROM FINAL PAY
____________ = $___________
G
BI-WEEKLY PAYROLL ($____________) CREDIT CARD THROUGH ACCOUNTING
METHOD: G POST DATED CHEQUES (ENCLOSED)
G
CARD NUMBER
EXP:
I acknowledge that I must arrange for payment of my benefit in order for benefit coverage to be maintained. If I fail to make the payments UPEI has the right to terminate coverage until a new payment schedule is arranged. I am aware that the above rates are subject to change by the insurer and I am responsible for any payments that may arise from any change in rates.
EMPLOYEE SIGNATURE:
DATE:
WITNESS
DATE: