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Forms & Downloads - FNIS Group Insurance Association Plan
FNIS Group Insurance Association Plan
Application / Data Changes

FNIS Plan Group Insurance Application/Data Change Form

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.
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  • Declaration-ER: To be completed by the First Nation/Organization Administrator. Print and complete this form on your Employer Letterhead listing your First Nation employees who ordinarily live on reserve in order to exclude them from the addition of Provincial Sales Tax (PST) to their Group Insurance premium.
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  • Declaration-EE: To be completed by the First Nation/Organization Employee. Print and complete this form on your Employer Letterhead, if you ordinarily live on reserve in order to exclude the addition of Provincial Sales Tax (PST) to your Group Insurance premiums.
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Guardianship Agreement Form

Effective August 1, 2017, the Provincial Government implemented new legislation requiring all employees who work and/or live in Saskatchewan to pay Provincial Sales Tax (PST) on their Group Insurance premiums. The Government has made exception to First Nation employees who ordinarily live on reserve provided we receive a completed declaration by or on behalf of employees who fall under this exemption rule. We have drafted a few declarations you can print and complete on your letterhead. Please forward the applicable form to our office for processing once completed, signed and dated.

Voluntary Accident Insurance Enrollment Form

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 Limited Partnership's office for processing. Contact your plan administrator or FNIS for current rates. Download Form

Beneficiary Change Form

If the plan member wishes to make a subsequent beneficiary designation to their Voluntary AD&D benefit please complete, sign and date the RBC Beneficiary Change Form then return it to our FNIS office for processing. Download Form

Statement of Health

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 of this form, sign it and return it to First Nations Insurance Services Limited Partnership's office for processing. Please contact your plan administrator or FNIS for rate bands. Download Form

Conversion Application

A former plan member who wishes to convert their group life insurance benefits (Basic, Optional and Spouse's Dependent Life) must complete/sign this form and attach a cheque for the first months premium as well as "VOID" cheque or the completed/signed "Bank Authorization" on the Conversion Application and return these requirements to our office within with the 31 day conversion period (31 days from date of termination of employment). Please contact First Nations Insurance for a quote. See attached conversion options.

Special Risk Conversion Form ($200k)

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. Download Form

Application for Accident Insurance Conversion

A former plan member must complete/sign this form and attach a cheque for the semi-annual or annual premium as well as a "VOID" cheque for the automatic withdrawal for the future monthly payments.

Blue Cross Group Conversion Plan & Pre-authorized Debit (PAD) Agreement
Former employee must complete these forms and submit forms for processing to First Nations Insurance Services Limited Partnership's office or the Insurer within 31 days of date of termination. See attched Conversion Plan.

 

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