Benefit plan form - Local Union 488

Edmonton Pipe Industry Benefit Plan

Privacy Policy: The Plans will collect, maintain and communicate only the personal Information considered necessary for the administartion of the Plans. Personal informaiton will be protected pursuant to the relevant legislation. The Plans may use and exchange information with relevant persons or organizations (health professionals, institutions, investigative agencies, insurers, re-insurers, regulators) in order to manage the Plans and your entitlement to the benefits of the Plans. Questions related to the Privacy Policy should be directed to the Executive Administrator.

Members Information

Name(Required)

First Middle Last

Social insurance Number(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Phone(Required)

Email(Required)

Dependant's Information

Number of Dependants

Name

First Middle Last

Dependant One

Date of birth

Dependant One

Sex

Dependant One

Relationship

Dependant One

Name

First Middle Last

Dependant Two

Date of birth

Dependant Two

Sex

Dependant Two

Relationship

Dependant Two

Name

First Middle Last

Dependant Three

Date of birth

Dependant Three

Sex

Dependant Three

Relationship

Dependant Three

Name

First Middle Last

Dependant Four

Date of birth

Dependant Four

Sex

Dependant Four

Relationship

Dependant Four

Name

First Middle Last

Dependant Five

Date of birth

Dependant Five

Sex

Dependant Five

Relationship

Dependant Five

Name

First Middle Last

Dependant Six

Date of birth

Dependant Six

Sex

Dependant Six

Relationship

Dependant Six

Name

First Middle Last

Dependant Seven

Date of birth

Dependant Seven

Sex

Dependant Seven

Relationship

Dependant Seven

Beneficiary - Edmonton Pipe Industry Health and Welfare Plan

Name

First Middle Last

Relationship

Address

Street Address Address Line 2 City Province Postal Code

Beneficiary - Edmonton Pipe Industry Pension Plan

Name

First Middle Last

Relationship

Address

Street Address Address Line 2 City Province Postal Code