Retirees Dental Plan Application Please enable JavaScript in your browser to complete this form.1Your Information2Your Coverage3Your BankingLayoutYour first name *Your last name *Your prefered name (optional)Do you go by a something that's not your legal name? Please enter it here so we can address you as you like.LayoutStreet address *City *Province *LayoutPostal Code *Email *Phone Number *LayoutYour gender *MaleFemaleNon-binaryPrefer not to answerDate of birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Where did you retire from? (optional)NextLayoutWho needs coverage? *MeMe and my spouseMe, my spouse, and our dependent(s)*Your spouse's first and last name *Spouse's date of birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your spouse's gender *MaleFemaleNon-binaryPrefer not to answerDoes the spouse have other Dental coverage? (if the spouse has family coverage CLHIA guidelines will be applied, see below.)SingleFamilyNoneIf your spouse has other benefit coverage, claims will be paid according to Industry standards: First, your spouse must submit claims to their benefit plan (this is your spouse’s primary benefit plan). Next, submit the unpaid portion to your GSC plan (this is your spouse’s secondary plan). Your children’s claims: First, submit your children’s claims to the plan of the parent whose birthday falls earliest in the year regardless of the year of birth. (That’s the primary plan.) Next, submit the unpaid portion to the other parent’s plan (the secondary plan). In situations of separation or divorce, the following order applies when determining which of the adults are responsible for the coverage of the children: (1) the plan of the parent with custody of the child (3) the plan of the parent not having custody of thechild (2) the plan of the spouse of the parent with custody ofthe child (4) the plan of the spouse of the parent not having custody of the child Please indicate with an “S” below if your child is secondary with GSC. CLHIA guidelinesLayoutDependent's first and last name (1)*A dependent must be: under 21, the child of you or your spouse, and not in a formal relationship recognized by law, or under 25, attending a school recognized by the Income Tax Act of Canada, and financially dependent on you, or physically or mentally incapable of self-support, and were under 25 when they became financially dependent on you.Dependent's gender (1)MaleFemaleNon-binaryPrefer not to answerDate of birth (1)DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920LayoutDependent's first and last name (2)Date of birth (2)DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Dependent's gender (2)MaleFemaleNon-binaryPrefer not to answerLayoutDependent's first and last name (3) Date of birth (3)DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Dependent's gender (3) MaleFemaleNon-binaryPrefer not to answerIf you have more than three dependent children, please use this space to add their information.PreviousNextLayoutStart coverage on: *January 1February 1March 1April 1May 1June 1July 1August 1September 1October 1November 1December 1Year *20232024202520262027202820292030LayoutAccount Holder Name *Transit Number (5 digits) *Joint Account Holder Name (if applicable)Institution Number (3 digits) *Bank Name *Account Number *LayoutIf possible, please upload a picture of your VOID cheque or Pre-Authorised Payment Document to aid in verifying your banking information Click or drag a file to this area to upload. Application Confirmation *I/We have read and accept the pre-authorized debit agreement and accept the payment terms and conditions.I/We authorize RMS Retirement Management Services Ltd. (RMS) and the financial institution designated (or any other financial institution I may authorize at any time) to begin deductions as per my instruction, from the account referenced above for monthly recurring payments and/or one-time payments from time to time, for payment of premiums for all coverage applied for in this application. The premiums may be variable. Withdrawals will be made on the 1st of each month or the next business day. If a pre-authorized payment is returned due to insufficient funds (NSF), I/we authorize RMS to re-submit such payment, including any NSF charges. I/we may cancel this authorization at any time, subject to providing RMS at least fifteen (10) days before the next scheduled withdrawal (RMS contact information can be found using the “Contact Form” tab at the top of this page). If this is a joint account, I/we certify that no other signatures are required to withdraw funds from the account. These services are for Personal Use. If I/we notify RMS of changes to my banking information, RMS will send a letter confirming the change. They will also send a notification of any changes to my coverage or premium amount. RMS Retirement Services Ltd. endeavours to provide optimum notice of changes but such notice may or may not be received 10 days in advance of the date of change. Therefore, I/we agree to waive my right to receive 10 days’ notice of an increase or decrease in the amount of the pre-authorized debit (PAD) or the date of withdrawal of the PAD. Payors have certain recourse rights if any debit does not comply with these terms. For example, Payors have the right to receive a reimbursement for any PAD that is not authorized or is not consistent with this PAD Agreement. Payors may obtain more information on their recourse rights by contacting their financial institution or visiting www.payments.ca Submit
