M5726 S7 001241
User Manual: M5726
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PLAN MEMBER NAME I.D. NUMBER
(When Known)
REASON CODE
(See Below) EFFECTIVE DATE OF CHANGE(S) PLEASE INCLUDE DETAILS
TO: THE GREAT-WEST LIFE ASSURANCE COMPANY
P.O. BOX 6000
WINNIPEG, MANITOBA R3C 3A5
FAX #: 204.946.4101
ATTN: MEMBER ADMINISTRATION
GROUP INSURANCE ADJUSTMENTS PLAN SPONSOR
PLAN NUMBER DIV. NO. DATE
(Please Print)
COMPLETED BY:
AREA CODE & PHONE #: ( )
PREPARE IN DUPLICATE
1 COPY TO GWL
1 COPY FOR YOUR RECORDS
* REASON CODES 1, 12 & 16
ARE NOT REQUIRED FOR
DIVISIONS MAINTAINED FOR
CLAIMS PURPOSES ONLY
M5726 BIL-3/15 ©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.
REASON CODES (Please insert the applicable Reason Code for each plan member in the column above)
1 – EARNINGS CHANGE*
2 – DEPENDANT - 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 – TERMINATION - Employment
8 – TERMINATION - 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)]
11 – REINSTATEMENT [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)
Clear
