Coverage Statement

for LUAI ABDEL-RAHIM Employee 102515 Printed On 09/30/2021 3:8:17 AM

159 SAINT-EMILLION
GATINEAU, QC
J8R2R5

Your Flex Credits

Flexible Credits linked to your choice of Medical $2,830.00
And Dental Benefits
Salary-Based Flexible Credits $201.00
Total $3,031.00

Your Benefits
Coverage Effective Dates
Start : May 16,2021 End : October 31,2021

Benefit Coverage Level Annual Flexible Payroll Deductions

Price Tag Credits Annual Per Pay
Used
Short-Term Option 1 $227.00 $227.00 $0.00 $0.00
Disability $291.00
Single
09/07/2019

Medical Option 2 $1,118.00 $1,118.00 $0.00 $0.00

Single
09/07/2019

Dental Option 2 $483.00 $483.00 $0.00 $0.00

Single
09/07/2019

Accidental Option 1 $10.00 $10.00 $0.00 $0.00

Dismemberment $50,000.00
Insurance
Single
09/07/2019

Basic Life Insurance 1 x Salary $28.00 $28.00 $0.00 $0.00

For You $21,000.00

09/07/2019

Optional Life No Coverage $0.00 $0.00 $0.00 $0.00

Insurance For You* $0.00
 09/07/2019

Optional Life No Coverage $0.00 $0.00 $0.00 $0.00

Insurance For You* $0.00
Smoker
09/07/2019

Long-Term Option 1 $198.00 $0.00 $198.00 $7.62

Disability $1,118.00
Single
05/16/2021

Totals: $2,064.00 $1,866.00 $198.00 $7.62

*
In order to elect coverage under Employee Optional Life Insurance, you must select Option 2 under Employee
Basic Life Insurance

Your Excess Flexible Credits

You have $1,000.00 in excess Flexible Credits

Health Care Spending Account (HCSA) $1,000.00

Group RRSP $0.00
Taxable Cash $0.00

Dependents

Covered Under Your Plan Covered Under Another Plan

Name Relationship Medical Dental Medical Dental
No Dependents On File

Your Beneficiaries

Basic Life Insurance For You

Name Relationship Birth Date Designation Date Of Benefits

(mm/dd/yyyy) Change
Waiting for Beneficiary Authorization Form to be signed and returned
Primary
test bene Spouse or 01/22/1985 Revocable 100.00 %
Partner