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Please print and complete pages form. required, retain photocopy your files. GL2971E(Snet)( ) (03/2011) Group Benefits - e-Enrolment Re-enrolment Application 3 Plan member address Address (number, street, apt. number) City Province Postal code 4 Applying coverage Health Dental Applying Health Dental Benefits

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Print type. See. Specific Instructions . page 3. 1. (as shown your income tax return). is required this line; not leave line blank. 2. Business name/disregarded entity name, different above. 3. Check box federal tax classification the person name entered line 1. Check .

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