Fillable Application To Group Insurance Form printable pdf download

MEMBERSHIP APPLICATION TO GROUP INSURANCE

(COMPLETE 1-2-4-5-6-7)

MODIFICATIONS TO GROUP INSURANCE

(COMPLETE 1-2-3-4-6-7 AND 5 IF NECESSARY)

La Capitale Insurance and Financial Services Inc.

625 Saint-Amable St, PO Box 1500, Quebec QC G1K 8X9

GROUP NO.

EMPLOYER NO.

CLASS

IDENTIFICATION NO.

418 644-4200 or 1 800 463-4856 • Fax: 418 646-1313 •

1- INFORMATION RELATING TO PARTICIPANT

NAME OF

NAME OF THE

EMPLOYEE

THE GROUP

EMPLOYER

NO.

FAMILY

FIRST

GENDER

DATE OF



NAME

BIRTH

NO.

STREET

APT.

CORRESPONDENCE

PHONE

ADDRESS



AT HOME

POSTAL

PHONE

CITY

CODE

AT WORK

TIME WORK

CIVIL STATUS



FULL



SINGLE OR

MARRIED*

WIDOWED*

COMMON LAW SPOUSE*

DIVORCED*

SEPARATED*

CIVIL UNION*



PARTIAL : ______________

(%)

* SINCE: _______________________________

STATUS

JOB

ANNUAL

EMPLOYMENT

ELIGIBILITY



PERMANENT

TITLE

SALARY

DATE



OTHER (

) : _______________________

SPECIFY

2- COVERAGE(S)

–

HEALTH INSURANCE (

)

INCLUDING VISION CARE, IF PROVIDED UNDER THE CONTRACT



INDIVIDUAL PLAN



* IMPORTANT :

SINGLE PARENT (IF PROVIDED UNDER THE CONTRACT)



COUPLE PLAN (IF PROVIDED UNDER THE CONTRACT)



To be exempted for health or dental

FAMILY PLAN



care insurance, the employee must

EXEMPTION*

prove to his employer that he or

–

DENTAL CARE

she is covered under another plan



INDIVIDUAL PLAN

offering similar benefits.



SINGLE PARENT (IF PROVIDED UNDER THE CONTRACT)



COUPLE PLAN (IF PROVIDED UNDER THE CONTRACT)



FAMILY PLAN



EXEMPTION*



–

PARTICIPANT’S BASIC LIFE INSURANCE (

)

INCLUDING DEATH & DISMEMBERMENT, IF PROVIDED UNDER THE CONTRACT



–

DEPENDENT’S LIFE INSURANCE



–

OPTIONAL LIFE INSURANCE

These coverages are subject to the

†

PARTICIPANT

– AMOUNT: ____________________ $

†



(IF PROVIDED UNDER THE CONTRACT)

SPOUSE’S

– AMOUNT: ____________________ $

Insurer’s approval of evidence of



DEPENDENT CHILDREN – AMOUNT: ____________________ $

insurability. Please complete the



Declaration of Insurability form.

–

CRITICAL ILLNESS INSURANCE

PARTICIPANT



(IF PROVIDED UNDER THE CONTRACT)

SPOUSE



DEPENDENT CHILDREN



–

SHORT – TERM DISABILITY INSURANCE



–

LONG – TERM DISABILITY INSURANCE



Were you covered under a disability insurance plan with your former employer?

Yes

Previous Insurer:

Since what date?



DIRECT DEPOSIT SERVICE FOR REIMBURSEMENT OF HEALTHCARE EXPENSES

I authorize La Capitale Insurance and Financial Services Inc. to deposit my Health Insurance and/or

Dental Care Insurance benefits in my bank account. (Please complete the following bank information; no cheque specimen is required).

Branch No.

Institution No.

Account No.

3- MODIFICATIONS

EFFECTIVE DATE

REASON(S) ____________________________________________________________________________________________________________________________________

LEAVE OF ABSENCE, PARENTAL LEAVE, MATERNITY, TEMPORARY LAY OFF, BIRTH, MARRIAGE, DISABILITY, ETC.

PLEASE :



DATE OF RETURN (IF APPLICABLE)

MODIFY MY GROUP INSURANCE COVERAGE(S) CHECK (✓) AGAIN ALL COVERAGES CHOSEN (PART 2)



RETAIN ALL COVERAGES IN MY GROUP INSURANCE



CANCEL ALL COVERAGES IN MY GROUP INSURANCE EXCEPT DRUG INSURANCE COVERAGE

4- IDENTIFY YOUR DEPENDENTS

First name

Family name

Gender

Date of birth

Student

First name

Family name

Sexe

Date of birth

Student

M F

 



Spouse:

Children:

 



 



Children:

 



 



5- BENEFICIARY’S FULL NAME

ATTENTION: THE DESIGNATION OF AN IRREVOCABLE BENEFICIARY INVOLVES SIGNIFICANT CONSEQUENCES. HIS CONSENT WILL BE

(FOR LIFE INSURANCE COVERAGES)

ABSOLUTELY NECESSARY IF YOU WANT TO REPLACE HIM AND, IF A MINOR, THE CONSENT OF HIS TUTOR WILL HAVE TO BE OBTAINED.

MARK YOUR CHOICE



DESIGNATION: ____________________________________________________________________________________________________________________________________

REVOCABLE

IRREVOCABLE

RELATIONSHIP WITH THE PARTICIPANT: ____________________________________________________________________________________________________________

6- DECLARATION OF THE PARTICIPANT

“I hereby authorize my employer to deduct the required premiums from my salary, La Capitale Insurance and Financial Services Inc. (hereinafter mentioned

La Capitale) and the person responsible for the plan to use my social insurance number for administration. Furthermore, I authorize any physician, any other

professional and intervening party in the field of health and rehabilitation, as well as any public or private health or social services institution, any insurance

company, as well as any reinsurer, any public or private organization, any information agency that will have received such a mandate, any market intermediary,

any employer or ex-employer, the policy holder as well as any person holding personal files or information, especially medical records pertaining to me, as

the case may be, to provide to La Capitale or to its mandataries, any information that it holds, required for the processing of my file.

I also authorize La Capitale to transmit such information to the aforementioned persons when necessary, within the scope of its activities and the processing

of my file. In the event of death, I specifically authorize the policyholder, the employer, the beneficiary, the heir or the liquidator of my succession to provide

La Capitale or its mandataries when necessary, with all information or authorizations permitting the processing of my file.”

This consent is valid for the purposes of this contract, its amendment, extension or renewal. A photocopy of this consent has the same value as the original.

______________________________________________________________________________

________________________________________

_____________________________________________________

Signature of the participant or, if under age, that of his or her legal representative

Phone number

Date

(PLEASE CONSULT THE NOTICE ON REVERSE)

7- SIGNATURE OF THE EMPLOYER

______________________________________________________________________________

________________________________________

_____________________________________________________

Phone number