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Registration form

Please complete the following form to register.

SIN *

First Name *

Last Name *

E-Mail *

Date Of Birth *

Mailing Address *

City *

Province *

Postal Code *

Phone *

Date Of Employment *

Employment Status *

Marital Status *

DEFINITION OF DEPENDANT

“Dependant” means your Spouse and Dependant Children.

“Spouse” means a person who is legally married to you, and is living with you, or a person living with you in a common-law relationship if such person is publicly represented by you as your husband or wife and such person has been living with you for a period of at least:

(a) one continuous year if neither of you are married; or
(b) 3 continuous years if either of you remain legally married to another person.

If you do not list a common-law Spouse on your initial Registration Form, such person must subsequently be listed on the records of the Administrator, for at least 12 months prior to becoming eligible for benefits.

If you have more than one Spouse, the person last designated by you, and filed with the Administrator, in writing, shall be considered to be your Spouse.

“Dependant Child” means your unemployed, unmarried, natural or legally adopted child, stepchild, a child over whom you have legal guardianship, or the child of a common-law Spouse, who is:

(a) under 18 years of age; or
(b) 18 years of age or older but less than 25 years of age and is enrolled in and attending a full curriculum of education at a recognized school, college or university; or
(c) 18 years of age or older and is not capable of self-sustaining employment by reason of mental or physical disability which commenced prior to the child’s 18th birthday,

provided you or your common-law Spouse contribute regularly to the support of such child.

A child of a common-law Spouse is considered to be a Dependant, after the child has lived with you for a minimum of 12 consecutive months.

Your common-law Spouse and the children of your common-law Spouse must be listed on this form. If not listed, or you enter into such a relationship after completing this form, they must be listed on the Administrator’s records for at least 12 months in order to be considered to be your Dependant.

Do you have Dependants living with you? Yes, I have Dependants as described above. No

Any Life or Accidental Death payment will be made to your estate. If you would like to designate a beneficiary please complete a Designation of Beneficiary Form and submit it to PBAS.

IMPORTANT:I hereby authorize the Board of Trustees and the service agencies they employ to: collect, record, use, disclose and, if applicable, destroy the personal information noted on this form. This authorization will survive as long as this information is needed to fulfill my benefit entitlements, or until I revoke it in a manner that does not contravene the law. However, I realize that if I withhold or revoke my consent to its use, thereby limiting or restricting the ability to determine coverage and benefit entitlement, my participation in the Plan may be impaired or cancelled.

I authorize the use of my Social Insurance Number as an additional verification of my identity in the administration of my benefit entitlements. I understand that my Social Insurance Number will be kept in the strictest confidence and will only be used for the specified purpose.

Furthermore, I certify that the information, given on this form, is true, correct, and complete, to the best of my knowledge and belief.