Absence From Work Form

in Form

Please fill out the Absence From Work Form below. Click the PREVIEW button located at the bottom of the form to check whether the form has been filled out completely. If so, then the PRINT button will allow you to print and add signatures.

Please mail this form to:

PBAS
110-61 International Blvd.
Toronto, ON M9W 6K4


Absence From Work Form

Part I – Employee

First Name: Last Name:
Member ID/SIN: Phone #:
Address:
City: Postal:

Part II – Employer

Company:
This employee has been absent from work due to: (please check one)
(a) Occupational Injury or Illness
(b) Non Occupational Injury or Illness
(c) Lay Off
(d) Maternity/Parental Leave
(e) Other
(f) Approved Leave of absence
(other than option (d))
Date absence Commenced:
Date Expected Return to Work:
Full Name: Title:
Phone #: Date:
Email:
Authorized Signature:  

Part III – Employee

Self payments can be made to continue dental coverage IF absence is due to Lay Off, Leave of absence, or Early Retirement.
Please check with the Plan Administrator prior to submitting any payment.
I wish to make self payment(s) for the month(s) of .
I have enclosed a cheque, or money order in the amount of $ , payable to the United Food and Commercial Workers Trusteed Dental Fund – Ontario.
I hereby certify that I have not engaged in any occupation or employment, other than with an employer participating in the plan, since my absence commenced.
Signature: Date:
Telephone (416) 674-3350 | Toll-Free 1 800-461-4361 | Fax (416) 674-1525 | www.theontariodentalplan.ca
Suite 110, 61 International Blvd., Toronto, Ontario M9W 6K4
©2012-2015 United Food and Commercial Workers Trusteed Dental Plan - Ontario
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