Certification For Uhip Exemption Form

ADVERTISEMENT

How to complete the Certification for UHIP® Exemption Form
• Print clearly in pen, using block letters.
• Enter all dates numerically (4 numbers for year, 2 numbers each for month and day).
• Check appropriate box to indicate type of application (initial request for recognition or
annual reconfirmation).
• Read the introduction carefully, and follow the instructions.
• Once completed, send a photocopy to the UHIP® insurer at the address on the form.
Certification for
|
4
Plan sponsor authorization and signature
(To be completed by plan sponsor (policyholder) and insurance company)
UHIP® Exemption
This is to certify that the above individuals have group health and medical insurance coverage that is at
least equal to the coverage provided under UHIP® (plan summary on reverse side), which coverage will be
effective throughout the period indicated above. Coverage is provided under Policy
_______________________
a
Policy number
issued by
____________________________________________
, an insurance company licensed under the laws
Sun Life Assurance Company of Canada – 50150
of ___________________________________________. Full premiums for the period indicated above have been
Your privacy is important to us. To view Sun Life Financial’s privacy policy please refer to or to
received from or on behalf of the above individuals. Complete details (in English or French) of all benefits
the UHIP® booklet “University Heath Insurance Plan (UHIP®) your basic health care solution” which can be
found at
provided under Policy
______________________________
relating to the above individuals are attached.
Annual reconfirmation is required to ensure that no plan design changes have been made to your coverage
Should the above individuals incur medical or health expenses during the period indicated above that would
even if you previously received recognition of at least equal coverage.
have been covered by UHIP® had the individuals been enrolled therein, it is agreed that such expenses will
be a liability of and be paid for either by the insurance coverage described herein, or in default of insurance
You must complete this form no more than 45 days after you join UHIP. Any forms completed after
Please PRINT clearly.
being available, by the plan sponsor (policyholder). The plan sponsor agrees to hold harmless any university
45 days from joining UHIP will not be considered.
|
attended by the applicant against any contingent liabilities whatsoever.
1
Certification details
Plan sponsor
Signature of authorized officer
per (Name of plan sponsor (policyholder)
a
Note: Completion of this
The University Health Insurance Plan (UHIP®), insured by Sun Life Assurance Company of Canada, a
(policyholder)
X
form does not necessarily
member of the Sun Life Financial group of companies (the insurer), is a program that provides basic coverage
guarantee exemption from
for most medically necessary services and supplies covered by the Ontario Health Insurance Plan (OHIP).
Name (please print)
Corporate seal
UHIP®. Final acceptance of
Participation in UHIP® is compulsory for all members and dependants, unless they can demonstrate – by
determination of at least
completion of this form – that they have group health and medical coverage under a plan that is recognized
equal coverage is subject
Title
as at least equal to the coverage provided under UHIP®. The compulsory nature of UHIP®, as well as the
to the approval of the
comparable requirements described, is intended to ensure that all universities are held harmless for any claims
UHIP® insurer.
Telephone number
that are eligible for reimbursement under UHIP®, as indicated in the plan summary on the reverse side.
You must enrol in UHIP® while applying for recognition of existing coverage. If your plan is recognized, 100%
of the UHIP® premium paid will be reimbursed, less any claims against the plan.
Address (street number and name)
Apartment or suite
Complete sections 2 and 3 in full. Send the form to your plan sponsor to complete section 4. This form must
be completed and signed by an authorized officer of your plan sponsor’s organization, and an authorized
Insurance company
Signature of authorized officer
per (Name of insurance company)
officer of the insurance company.
X
Completed form is to be sent to the insurer at the address below. Complete plan details must
Name (please print)
Corporate seal
accompany this form, including all plan limits and exclusions.
|
2
Member details
(To be completed by member)
Title
a
Please PRINT clearly.
University name
Date request submmitted (dd-mm-yyyy)
Telephone number
b
Name of plan sponsor (policyholder) and insurance company
Address (street number and name)
Apartment or suite
c
Member’s last name
First name
Date of birth (dd-mm-yyyy)
Return completed form to
For more information,
Dependant’s last name
First name
Date of birth (dd-mm-yyyy)
Sun Life Assurance Company of Canada
contact Sun Life Assurance Company of Canada at
Association & Affinity Business
• toll free
1-877-250-UHIP (8447)
d
PO Box 4097 Station A
• e-mail
Canadian address (street number and name)
Apartment or suite
Toronto ON
Hours of operation from Monday to Friday
M5W 2Z5 CANADA
8:30 to 5:00 Eastern Standard Time
City
Province
Postal code
e
Office use only
Member ID #
Member telephone number
Date received (dd-mm-yyyy)
f
Effective dates of other coverage
From (dd-mm-yyyy)
To (dd-mm-yyyy)
|
3
Member authorization and signature
IMPORTANT:
I authorize Sun Life Assurance Company of Canada (the insurer), its agents and service providers, to use
this form for the purpose of benefits administration and to assess my request for an exemption from this
You must sign and date
the form.
coverage. The authorization is valid for the duration of the exemption assessment and thereafter during any
coverage provided to me under the plan.
a
Member’s signature
Date (dd-mm-yyyy)
X
Page 1 of 3
Page 2 of 3
AACF-UHIP-004-E-04-14
See plan summary on Page 3
AACF-UHIP-004-E-04-14
Section 1: Certification details
e) - Your UHIP® member identification number
- Your telephone number
a) P lease make sure you read and understand section 1
before continuing
f) Date that your protection under the other plan begins and ends
Section 2: Member details
Section 3: Member authorization and signature
a) - University name
a) Y ou must sign and date this section for your application to
- Date you are completing the Certification for UHIP® Exemption
be processed.
b) C omplete the name of the plan for which you are requesting
Section 4: Plan sponsor authorization and signature
recognition and the insurer’s company name (if applicable)
a) Y ou must provide complete policy details to allow the
c) Y our full name: last, first, and middle, and the full names of
UHIP insurer to process your UHIP Exemption Request.
your family members (if they are also covered by the plan for
which you are requesting recognition).
d) C omplete Canadian address, including postal code, and
telephone number (or the International Student Advisor or
the university Human Resources Department)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Financial
Go