Employee Benefits Dependent Change Form

Important Information: This form is used to update information about your spouse and dependent children with 3sHealth Employee Benefits. If you wish to change your beneficiary for Group Life Insurance please call a 3sHealth Benefit Services Officer at 1-866-278-2301.

* Required

Personal Information:

Benefit ID ?

Title *

First Name *

Last Name *

Date of Birth *

Select or enter the date of birth in the format DD/MM/YYYY

Email Address *

3sHealth will only use this information if they have a question regarding the changes requested on this form.

Daytime Phone Number *

3sHealth will only use this information if they have a question regarding the changes requested on this form.

Add or Change Information about your Spouse:

Marital Status *

Has Your Marital Status Changed? Yes No

Relationship Effective Date

Represents the date you started living together as Common-Law (must be 12 months or more) or the date you were legally married. Select or enter the relationship effective date in the format DD/MM/YYYY

Spouse's First Name

Spouse's Last Name

Spouse's Date of Birth

Select or enter spouse's date of birth in the format DD/MM/YYYY

Spouse Information Change Effective Date

Select or enter the spouse information change effective date in the format DD/MM/YYYY

Add or Change Information about Dependent Children:

If you are making no changes to this section, skip to the bottom.

Remove your Spouse:

Spouse's First Name

Spouse's Last Name

Spouse's Date of Birth

Select or enter spouse's date of birth in the format DD/MM/YYYY

Spouse Removal Effective Date

Select or enter the spouse removal effective date in the format DD/MM/YYYY

Remove Dependent Children:

If you are making no changes to this section, skip to the bottom.

Submit Your Changes:

Acknowledgement: I hereby acknowledge that I have read and understand the conditions of the Employee Benefit Plans, as outlined in the Plans' commentaries available online at www.3sHealth.ca, and confirm the options I have chosen above. I understand these benefits are subject to the terms of the Group Life Insurance Plan, Disability Plan, Core Dental Plan, Enhanced Dental Plan and Extended Health Care Plan, as applicable, sponsored by Health Shared Services Saskatchewan.

I hereby expressly consent to the collection, use, and disclosure of my personal information by 3sHealth for the purpose of administering my benefits, for the purpose of sharing my information with future or replacement service providers relating to the administration of my benefits, and as otherwise provided in the 3sHealth Privacy Policy (available online at www.3sHealth.ca). I further consent to 3sHealth using my personal information in other 3sHealth systems, including the payroll system, where required for the administration or payment of my benefits.

By submitting this form on-line, I agree that the information provided is complete and accurate.

3sHealth Employee Benefits is committed to protecting the privacy of your personal information. We collect and use your personal information to determine your eligibility for coverage and to administer the benefit plans. We limit access to your personal information to 3sHealth Employee Benefits staff, to any third party authorized by 3sHealth who requires it to administer your benefits, to persons to whom you have granted access, and to persons authorized by law.

Thank you for updating your information.

For more information on 3sHealth's Employee Benefits Plan visit www.3shealth.ca

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