Get Gl0514e Form

The Gl0514e Form is essential for applying for over-age disabled dependant coverage under group benefits. This guide provides a clear, step-by-step approach to complete the form online, ensuring you fill out each section accurately and completely.

Follow the steps to fill out the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section 1, which requires completion by the plan administrator. Fill in the plan sponsor name, plan contract number(s), plan member account/division, address, member certificate number, and member name. Ensure the administrator's signature is obtained to confirm terms.
3. In Section 2, provide the plan member information. This includes the last name, first name, middle initial, address, city and province, and member certificate number.
4. Section 4 needs to be filled out by the attending physician. Include their full name, address, contact details, and clinical diagnosis. Provide additional responses about the condition's impact on normal activities and the patient's work capabilities.
5. In Section 5, the plan member must sign and date the declaration confirming the accuracy of the information provided. Ensure to furnish the mailing instructions for submitting the form.
6. Once all sections are completed, save your changes, download a copy for your records, and print or share the form as necessary.

Complete your documentation online today to ensure your application is processed efficiently.