M5726 S7 001241

User Manual: M5726

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GROUP INSURANCE ADJUSTMENTS

PLAN SPONSOR
PLAN NUMBER

TO:

THE GREAT-WEST LIFE ASSURANCE COMPANY

P.O. BOX 6000
WINNIPEG, MANITOBA R3C 3A5
FAX #: 204.946.4101
ATTN: MEMBER ADMINISTRATION
PLAN MEMBER NAME

PREPARE IN DUPLICATE
1 COPY TO GWL
1 COPY FOR YOUR RECORDS
*R
 EASON CODES 1, 12 & 16
ARE NOT REQUIRED FOR
DIVISIONS MAINTAINED FOR
CLAIMS PURPOSES ONLY

DIV. NO.

(Please Print)
COMPLETED BY:
AREA CODE & PHONE #: (

I.D. NUMBER
(When Known)

DATE

REASON CODE
EFFECTIVE DATE OF CHANGE(S)
(See Below)

)

PLEASE INCLUDE DETAILS

REASON CODES (Please insert the applicable Reason Code for each plan member in the column above)
1 – EARNINGS CHANGE*
2–D
 EPENDANT - Add coverage
[Attach Group Coverage Change Form
M6190 or M6190(f)]
3 – DEPENDANT - Delete coverage
4 – CLASS CHANGE
5 – WAIVED BENEFITS [Attach Group Coverage
Change Form M6190 or M6190(f)]

6 – TERMINATION - Layoff or Leave of Absence
7–T
 ERMINATION - Employment
8–T
 ERMINATION - Plan Member cancels
[Attach Group Coverage Change Form
M6190 or M6190(f)]
9 – DIVISION TRANSFER
10 – NEW PLAN MEMBER [Attach Application for
Group Coverage Form M6191 or M6191(f)]

M5726 BIL-3/15

Clear

11 – R
 EINSTATEMENT [Attach Group Coverage
Change Form M6190 or M6190(f)]
12 – BENEFICIARY CHANGE [Attach Group
Coverage Change Form M6190 or M6190(f)]*
13 – NAME CHANGE [Attach Group Coverage
Change Form M6190 or M6190(f)]
14 – OCCUPATION CHANGE

15 – PROVINCE OF RESIDENCE CHANGE
16 – PROVINCE OF WORK CHANGE*
17 – LOST OR STOLEN DRUG CARD
18 – REPLACE OR ADDITIONAL DRUG CARD
19 – RETIREMENT DATE
20 – OTHER (Describe briefly)

©The Great-West Life Assurance Company. All rights reserved. Any modification of this
document without the express written consent of Great-West Life is strictly prohibited.
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