MyCHOICE (Bargaining Unit) Benefit Forms To be used by Government of Alberta Employees who are members of the Alberta Union of Provincial Employees (AUPE) Bargaining Unit. Enrolment/Change Form Use this form to enroll dependents, remove dependents and/or enroll or change benefit selections under the group life insurance plan, health plan and dental plan. Statutory Declaration Use this form when a Statutory Declaration is required (generic in nature). Statutory Declaration - Eligible Benefit Recipient Use this form to enroll a Eligible Benefit Recipient in the group benefit plans. This form must be completed when an Employee has cohabited with their Eligible Benefit Recipient between 24 and 36 months. Claim Form - Health Services Use this form to submit claims for all health benefit products or services. Claim Form - Emergency Out-of-Country Expense Use this form to submit claims that occur outside of Alberta/Canada due to a medical emergency. NOTE: must have selected Enhanced Medical coverage in order to be eligible for Emergency Travel Plan coverage. Claim Form - Dental Services Use this form to submit claims for all dental services and procedures. Long Term Disability Income Continuance Plan - Employee's Statement Use this form to apply for Long Term Disability Income Continuance Plan benefits. Group Life Insurance - Evidence of Insurability Form Use this form to increase the amount of Basic Life Insurance coverage, or to apply or increase the amount under Enhanced Life Insurance. Some conditions apply. Group Life Insurance - Application and Declaration for Non-Smoker Rate Use this form if you are a non-smoker and are applying for Enhanced Life Insurance. Group Life Insurance - Designation of Beneficiary Form Use this form to designate beneficiaries for Group Life Insurance policy. Group Life Insurance - Advance Payment Use this form if the Employee is terminally ill and wishes to request an advance payment from their life insurance proceeds. Part I of this form must be completed by the Employing Ministry and Part II is by the Employee. Group Life Insurance - Advance Payment - Attending Physician's Statement Use this form if the Employee is terminally ill and wishes to request an advance payment from their life insurance proceeds. This form must be completed by the Employee’s Physician. Group Life Insurance - Claim for Accidental Dismemberment or Loss Use this form if claiming for accidental dismemberment or loss of use. Part I of this form must be completed by the Employing Ministry and Part II by the Employee. Group Life Insurance - Certificate of Attending Physician - Accidental Dismemberment or Loss Use this form if claiming for accidental dismemberment or loss of use. This form must be completed by the Employee’s Attending Physician.

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