Benefits Info Update Form

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Update Your Local's Benefits Information:

* Indicates required field

Your Name: *

First

Last

Your Title: *

Your Email: *

Local: *

Please only fill in the fields below that require updating.
All fields left blank will remain unchanged in the database.

Who is your benefit provider? *

Are your benefits under a paramedical umbrella? *

YES NO

If so, What's included under the umbrella? *

Massage Chiro Chiropodist Acupuncture Naturopath Osteopath Athletic Therapy Podiatrist Phychologist Speech Therapy Orthotics Physiotherapy Nutritionist Occupational Therapist

Any Additional Benefits Included Under the Umbrella? *

Do you have Accidental Death & Dismemberment Coverage? *

Yes No

If so, Please identify if there is coverage specific to Occupational Disease Claims: *

Do you have a WSIB Top up? *

YES NO

Coverage Amount: *

Is your spouse and/or dependants covered by all benefits? *

Yes No

Other? (Please Specify): *

Please enter the amounts below that are included in your current collective agreement.
These answers should be in the format of currency (i.e. $200)

Is Master benefit and/or policy provided to you by Employer? *

Yes No

Life Insurance Premium Paid by: *

Member Employer

Post 65 Benefit? *

Yes No

Coverage Amount? *

Private Nursing? *

Yes No

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

NATUROPATH *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Chiropractic *

Yes No

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

Massage *

Yes No

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

Acupuncture *

Yes No

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

Osteopath *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Athletic Therapy *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Podiatrist *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Chiropodist *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Psychologist *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Speech Therapy *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Orthotics *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

Physiotherapy *

Yes No

Coverage Amount: *

Per Visit Cap? *

Yes No

Amount of Cap? *

NUTRITIONIST *

Yes No

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

Occ. Therapist *

Yes No

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

Other? *

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

Other? *

Coverage Amount? *

Per Visit Cap? *

Yes No

Amount of Cap? *

Vision Care:

Vision Care? *

Yes No

Coverage Amount: *

Coverage Duration? *

12 months 24 months 36 months 48 months

Is eye exam included? *

Yes No

If eye exam is not included how much is separate coverage for eye exam? *

Other Optical Coverage? *

Laser Eye Contact Lenses

Hearing Benefits:

Hearing Aids? *

Yes No

Coverage Amount: *

Hearing Test Coverage? *

Yes No

Coverage Amount: *

What is the duration? *

12 months 24 months 36 months Lifetime

Survivor & Retiree Benefits:

Does your local have Survivor Benefits? *

Yes No

# of years covered: *

Are your benefits locked at retirement date values? *

Yes No

Do you have an Early Retirement Incentive Program (ERIP)? *

Yes No

If you have an ERIP, Please include the terms below: *

do you have a Seperate Coverage Plan for Retirees? *

Yes No

What is Covered Under Your Survivor Benefits? *

Do your Retiree Benefits Mirror Active Member Benefits? *

Yes No

How many Years of service required for benefit coverage qualification? *

LODD Benefits:

Identify how many times your salary your LODD benefit is: *

1x 2x 3x 4x

Other (Please Specify) *

How long is a spouse eligible to receive benefits following an LODD? *

1 Year 2 Years Normal Age of Retirement

Other (please specify): *

Drug Coverage:

Do you have any of the following included in your Collective Agreement?

Dispensing Fee Cap? *

Yes No

Coverage Amount: *

Family Included? *

Single Family

Other? *

How do Generic Drugs apply to your plan? *

Mandatory Generics Generics only unless specfied by doctor

Please list any drug coverage co-pays and their amounts: *

i.e. Prescriptions, $5.00

Drug Coverage Deductible? *

Yes No

Deductible Amount? *

Long Term Disability (LTD):

Do you have a Long Term Disability (LTD) benefit? *

Yes No

Total Coverage Amount: *

Maximum amount per Month: *

Long Term Disability (LTD) Paid by: *

Paid by Employer Paid by Members Association Paid Association Paid with Reimbursement by Employer

% Amount: *

Sick Time Accrual:

Do you have a Sick Time Accrual Benefit? *

Yes No

How many days do you accumulate per month? *

Please identify the terms of your STD Plan: *

Dental Benefits:

Current ODA? *

Yes No

Previous Year ODA? *

Yes No

Orthodontic? *

Yes No

Coverage Amount: *

Any dental recall restrictions? *

Annually More None

Other? *

Do you have any annual Deductibles? *

Yes No

If so, Please list deductibles: *

Dental Mjr Restorative? *

Yes No

Coverage Amount: *

Orthodontic Coverage For: *

Member Spouse Dependants Under 18

Time limitations for any dental coverages? *

Please List any dental benefits that have co-pays and their amounts *

i.e. Orthodontic, 50/50

Any Other Dental benefits not listed? *

Comments? *

Submit

If you have any questions at all, please contact jchambers@ontariofirefighters.org

© 2019 Ontario Professional Fire Fighters Association

Home
The OPFFA
Member Services
Database
- Database
- Update Database
Events
- Event Sponsorship *
Memorials & Funerals
SECTION 21