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rate guide and
application form
easy access® and
preferred access®
effective may 2013
Plan today for your family’s financial security.
Be sure your loved ones aren’t left with the burden of having
to pay final expenses during their time of grief.
With Easy Access® and Preferred Access® from
Medavie Blue Cross, you can have peace of mind.
Plan
for the
future.
The Benefits
Your Receipt
• For persons aged 40-85
• Level premiums guaranteed for life, payable to age 100
• Up to $35,000 of coverage
• No medical examinations
• Immediate death benefit
• No two-year waiting period
• Coverage guaranteed - won’t be reduced
• Cash values
• Face amount doubles if death occurs due to an accident
Please make your cheque payable to Medavie Blue Cross.
Medavie Blue Cross acknowledges receipt of the initial premium
payment of $
paid in connection with the application for
Easy Access life insurance on the life of in the amount of $
.
Signature of Agent
Date
Signature of Policy Owner
Attention Agent: No premium is to be collected or submitted if the Proposed Life Insured has answered “YES” to any of the first four medical questions on the Easy Access and Preferred Access Declaration.
Your satisfaction is guaranteed
We offer a 10-day right to examine your policy. If at any time within 10 days of receipt of
your policy you are dissatisfied, simply return it to Medavie Blue Cross and we’ll refund any
premiums you have paid. Your satisfaction is important to us.
1
Annual Rates
Monthly Rates (PAD)
Rates per $1,000. Based on Age Last Birthday.
Annual Policy Fee of $50.
Easy Access Annual Rates
Non-
smoker Smoker
Non-
smoker Smoker
Non-
smoker
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
17.88
18.48
18.96
19.56
20.28
21.00
21.60
22.32
23.16
24.00
24.96
26.04
27.36
28.68
30.12
31.56
33.12
34.80
36.48
38.40
40.44
42.60
44.88
47.28
50.04
53.04
56.28
59.76
63.48
67.56
72.12
76.92
81.84
87.36
93.36
100.20
107.52
114.96
123.36
133.20
145.08
159.12
174.84
192.36
211.44
232.20
27.36
28.08
28.92
29.76
30.84
31.92
33.24
34.56
36.00
37.44
39.00
40.68
42.24
43.92
45.84
47.76
49.92
52.20
54.60
57.12
60.00
63.00
66.12
69.60
73.32
77.28
81.60
86.16
91.08
96.36
102.36
108.72
115.44
122.76
130.80
139.92
149.88
160.44
171.96
184.68
198.60
213.84
230.16
247.68
266.40
286.32
12.96
13.44
14.04
14.76
15.60
16.56
17.64
18.72
20.04
21.36
22.80
24.12
25.32
26.76
28.20
29.88
31.68
33.72
35.88
38.04
40.20
42.12
44.04
46.08
48.36
51.24
54.72
58.56
62.76
67.32
71.88
76.56
81.36
86.52
91.92
97.80
103.44
108.84
114.84
122.88
133.92
147.96
164.28
182.88
203.76
226.92
9.48
9.84
10.32
10.80
11.40
12.00
12.84
13.68
14.76
15.72
16.68
17.64
18.60
19.56
20.64
21.84
23.16
24.60
26.16
27.84
29.52
31.08
32.88
34.56
36.60
38.76
41.28
43.92
46.80
49.92
53.28
56.88
60.60
64.68
69.00
73.80
78.60
83.28
88.44
95.04
103.56
114.00
126.00
139.44
154.44
171.00
36.60
37.80
39.12
40.56
42.12
43.80
45.60
47.64
49.68
51.96
54.36
57.00
59.76
62.64
65.88
69.36
72.96
76.92
81.00
85.44
90.24
95.40
100.80
106.56
112.80
119.40
126.36
133.68
141.48
149.88
159.00
168.72
178.92
189.96
201.72
214.56
227.88
241.56
256.44
273.24
292.68
314.88
339.24
365.76
394.56
425.52
Preferred
Access Annual Rates
Male
Age Non-
smoker Smoker
21.36
22.08
22.92
23.76
24.72
25.68
26.64
27.72
28.80
30.12
31.44
32.88
34.44
36.12
38.04
39.96
42.12
44.52
46.92
49.68
52.68
55.80
59.28
62.88
66.84
71.28
76.08
81.12
86.64
92.64
99.12
106.20
113.76
121.80
130.68
140.40
150.48
161.04
172.44
185.52
200.88
218.52
237.96
259.20
282.24
307.20
Female
Rates per $1,000. Based on Age Last Birthday.
Monthly Policy Fee of $4.50.
Male
25.44
26.40
27.72
29.04
30.48
32.16
33.96
35.88
38.04
40.20
42.36
44.64
46.92
49.32
51.84
54.60
57.48
60.60
63.84
67.20
70.80
74.64
78.60
82.80
87.12
91.80
96.72
101.76
107.04
112.68
118.68
125.04
131.76
138.72
146.28
154.20
161.28
167.40
174.72
185.28
201.00
221.88
246.72
275.40
307.92
344.40
Female
Easy Access
Preferred Access Monthly Rates
Smoker
Non-
smoker 18.60
19.32
20.04
21.00
21.96
22.92
24.12
25.32
26.76
28.08
29.52
30.96
32.40
33.96
35.64
37.32
39.24
41.16
43.32
45.60
48.00
50.52
53.28
56.04
59.16
62.40
65.88
69.48
73.44
77.52
82.08
86.88
91.80
97.08
103.08
109.92
117.24
124.80
133.20
143.16
155.28
169.68
185.64
203.40
222.96
244.08
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
1.61 2.46 1.17 1.66 2.53 1.21 1.71 2.60 1.26 1.76 2.68 1.33 1.83 2.78 1.40 1.89 2.87 1.49 1.94 2.99 1.59 2.01 3.11 1.68 2.08 3.24 1.80 2.16 3.37 1.92 2.25 3.51 2.05 2.34 3.66 2.17 2.46 3.80 2.28 2.58 3.95 2.41 2.71 4.13 2.54 2.84 4.30 2.69 2.98 4.49 2.85 3.13 4.70 3.03 3.28 4.91 3.23 3.46 5.14 3.42 3.64 5.40 3.62 3.83 5.67 3.79 4.04 5.95 3.96 4.26 6.26 4.15 4.50 6.60 4.35 4.77 6.96 4.61 5.07 7.34 4.92 5.38 7.75 5.27 5.71 8.20 5.65 6.08 8.67 6.06 6.49 9.21 6.47 6.92 9.78 6.89 7.37 10.39 7.32 7.86 11.05 7.79 8.40 11.77 8.27 9.02 12.59 8.80 9.68 13.49 9.31 10.35 14.44 9.80 11.10 15.48 10.34 11.99 16.62 11.06 13.06 17.87 12.05 14.32 19.25 13.32 15.74 20.71 14.79 17.31 22.29 16.46 19.03 23.98 18.34 20.90 25.77 20.42 1.92 1.99 2.06 2.14 2.22 2.31 2.40 2.49 2.59 2.71 2.83 2.96 3.10 3.25 3.42 3.60 3.79 4.01 4.22 4.47 4.74 5.02 5.34 5.66 6.02 6.42 6.85 7.30 7.80 8.34 8.92 9.56 10.24 10.96 11.76 12.64 13.54 14.49 15.52 16.70 18.08 19.67 21.42 23.33 25.40 27.65 3.29 3.40 3.52 3.65 3.79 3.94 4.10 4.29 4.47 4.68 4.89 5.13 5.38 5.64 5.93 6.24 6.57 6.92 7.29 7.69 8.12 8.59 9.07 9.59 10.15 10.75 11.37 12.03 12.73 13.49 14.31 15.18 16.10 17.10 18.15 19.31 20.51 21.74 23.08 24.59 26.34 28.34 30.53 32.92 35.51 38.30 Female
Female
Male
Male
Age Non-
smoker Smoker
Non-
Smoker smoker Smoker
2.29 2.38 2.49 2.61 2.74 2.89 3.06 3.23 3.42 3.62 3.81 4.02 4.22 4.44 4.67 4.91 5.17 5.45 5.75 6.05 6.37 6.72 7.07 7.45 7.84 8.26 8.70 9.16 9.63 10.14 10.68 11.25 11.86 12.48 13.17 13.88 14.52 15.07 15.72 16.68 18.09 19.97 22.20 24.79 27.71 31.00 Non-
smoker
Smoker
0.85 0.89 0.93 0.97 1.03 1.08 1.16 1.23 1.33 1.41 1.50 1.59 1.67 1.76 1.86 1.97 2.08 2.21 2.35 2.51 2.66 2.80 2.96 3.11 3.29 3.49 3.72 3.95 4.21 4.49 4.80 5.12 5.45 5.82 6.21 6.64 7.07 7.50 7.96 8.55 9.32 10.26 11.34 12.55 13.90 15.39 1.67
1.74
1.80
1.89
1.98
2.06
2.17
2.28
2.41
2.53
2.66
2.79
2.92
3.06
3.21
3.36
3.53
3.70
3.90
4.10
4.32
4.55
4.80
5.04
5.32
5.62
5.93
6.25
6.61
6.98
7.39
7.82
8.26
8.74
9.28
9.89
10.55
11.23
11.99
12.88
13.98
15.27
16.71
18.31
20.07
21.97
Minimum Premium $200 Yearly, $20 Monthly
For other billing frequencies, multiply Annual Rates by:
Quarterly billing: multiply by .27
Semi-annual billing: multiply by .525
2
Cash Values
Per $1,000 of face amount
Easy Access®
Age Last
Birthday*
Male/Female
Cash Values at the End of:
40
45
50
55
60
65
70
75
80
85
3 Years
$ 25
30
35
45
60
80
110
145
175
195
5 Years
10 Years
$ 27
32
40
55
75
100
145
175
210
235
15 Years
$ 32
40
55
80
110
150
195
250
350
485
$ 45
60
85
115
165
225
285
395
565
1,000
20 Years
$ 69
90
125
180
250
330
420
620
1,000
_
Preferred Access®
Female
Age Last
Birthday*
40
45
50
55
60
65
70
75
80
85
Cash Values at the End of:
3 Years
$ 17
20
24
30
41
54
74
98
118
132
5 Years
10 Years
$ 18
23
28
38
53
72
105
132
153
181
15 Years
$ 24
29
41
60
85
120
166
240
302
484
$ 34
46
67
94
139
201
277
396
564
1,000
20 Years
$ 56
74
105
158
229
324
421
619
1,000
_
Male
Age Last
Birthday*
40
45
50
55
60
65
70
75
80
85
Cash Values at the End of:
3 Years
$ 21
25
29
37
50
66
91
120
144
161
5 Years
$ 22
27
33
46
63
84
124
152
179
206
10 Years
$ 27
34
47
70
97
134
179
245
324
485
15 Years
$ 39
53
76
104
151
212
281
395
565
1,000
20 Years
$ 62
81
114
168
239
327
420
620
1,000
_
*Age Last Birthday is based on the age of the life insured as of the policy effective date.
3
Complete listing of cash values available upon request.
PO BOX 220
MONCTON NB E1C 8L3
TEL: 1-800-667-4511
FAX: 506-869-9654
Application for Life Insurance
Benefits are underwritten by Blue Cross Life Insurance Company of Canada
Name of Proposed Life Insured
Name:
First
Middle
Last
Mailing Address:
City/Town:
Province:
Postal Code:
Telephone:
Date of Birth:
Age Last Birthday:
Occupation:
(Day/Month/Year)
Gender:
Male
Female
Name of Policy Owner
Name:
(If different from Proposed Life Insured)
First
Middle
Last
Mailing Address:
City/Town:
Province:
Telephone:
Postal Code:
Relationship to Proposed Life Insured:
-
-
Name of Contingent Policy Owner:
Note: If no contingent policy owner is named, all of the policy owner’s rights and interest in this policy will be transferred to the policy owner’s estate
at the time of death of the policy owner.
  
U.S.
Residency Tax Information
Tax residency information must be completed by the policy owner. The proposed life insured is also the policy owner if no policy owner is
indicated.
Are you a US citizen or a US resident for tax purposes?
Yes Please provide your Individual Taxpayer Identification Number (ITIN) or SSN:
No
If a contingent policy owner is indicated, please also provide details.
Is the contingent policy owner a US citizen or a US resident for tax purposes?
Yes Please provide their Individual Taxpayer Identification Number (ITIN) or SSN:
No
  
Name
of Beneficiary or Beneficiaries
If more than one beneficiary, the proceeds will be divided in equal shares among surviving beneficiaries, unless otherwise indicated below.
Primary Beneficiary/Beneficiaries:
Name: Telephone:
-
Relationship to Life Insured:
% Share
Name: Telephone:
-
Relationship to Life Insured:
% Share
Name: Telephone:
-
-
Relationship to Life Insured:
% Share
Total 100%
Contingent Beneficiary/Beneficiaries:
Name: Telephone:
-
-
Relationship to Life Insured:
Name:
Telephone:
-
-
Relationship to Life Insured:
Face Amount Applied for
Easy Access
$ Premium $
Preferred Access
$ Premium $
Initial payment should always be based on Easy Access premium.
Please note: A physician’s signature will be required to verify medical information based on the following:
Easy AccessPreferred Access
Age 75-85 for any face amount
Age 40-59 for face amount over $10,000 Age 70-74 for face amount over $ 5,000
Age 60-69 for face amount over $ 7,500 Age 75-85 for any face amount
4
Method of Payment
A: Direct Billing:
Annual
Semi-annual
B: Monthly Pre-authorized Debit (PAD):
1st
Quarterly
15th
Please complete the Pre-authorized Debit (PAD) plan agreement below.
I/We authorize Medavie Blue Cross, and the financial institution designated (or any other financial institution I/we may authorize at any time) to begin
deductions as per my/our instructions for recurring payments and/or one-time payments from time to time, for payment of insurance premiums. Regular
monthly payments for the full amount of services delivered will be debited to my/our specified account on the day of the month indicated above. Medavie
Blue Cross will not provide monthly pre-notification but will provide 30 days notice if the deduction is subject to change. Medavie Blue Cross will obtain
my/our authorization for any other one-time or sporadic debits. Medavie Blue Cross requires written notification of any changes to banking information.
This authority is to remain in effect until Medavie Blue Cross has received written notification from me/us of its change or termination. This notification
must be received at least 30 business days before the next debit is scheduled. This notification must be sent to the Administration department of Medavie
Blue Cross. I/We may obtain a sample cancellation form or more information on my/our right to cancel a PAD Agreement at my/our financial institution
or by visiting www.cdnpay.ca.
I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any
PAD that is not authorized or is not consistent with this PAD Agreement. To obtain a form for a Reimbursement Claim, or for more information on my/our
recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca.
Type of Service:
Personal
Business
Please attach a void cheque. (Credit card payments are not accepted.)
Financial Institution (FI): (PLEASE PRINT)
Address:
City/Town:
Province:
FI Transit Number: (transit - 5 digits;
FI - 3 digits)
DATE:
Postal Code:
FI Account Number:
Authorized Signature(s):
If someone other than the Policy Owner will be paying the premiums, please have them sign above and complete their personal information below:
Name:
Address:
City/Town:
Province:
Phone Number: (Bus.)
-
-
(Res.)
Postal Code:
-
-
Agent Checklist
Prior to submitting applications, be sure to complete the following:
My client has signed the Easy Access and Preferred Access Declaration.
I’ve indicated in the “Note to Attending Physician” section what my client’s attending physician must verify and sign.
I’ve indicated my client’s bank authorization information on the application.
A void cheque is enclosed.
I’ve verified the identity of the applicant.
I’ve indicated my agent number below.
I’ve included a premium for Easy Access rate. (No post-dated cheques)
By signing below you confirm that you, the agent, have disclosed:
a) the company or companies you represent;
b) that you receive commissions for the sale of life and health insurance company products;
c) that you may receive additional compensation in the form of bonuses, conference programs or incentives; and
d) any conflicts of interest you may have in respect to this transaction.
Agent’s Name:
PLEASE PRINT
Agent’s Address:
Agent’s Number:
Phone Number:
Fax Number:
E-mail:
Signature:
Policy should be sent to:
5
Agent
Policy Owner
Note to Attending Physician
Name (Proposed Life Insured):
Date of Birth:
(Day / Month / Year )
Please review the answers to Medical Questions 1-4 within the Easy Access and Preferred Access Declaration below and confirm and sign the Easy Access section of the Attending Physician’s Verification on the next page.
OR
Please review the answers to Medical Questions 1-10 within the Easy Access and Preferred Access Declaration below and confirm and sign the
Preferred Access section of the Attending Physician’s Verification on the next page.
Easy Access® and Preferred Access® Declaration
Please note: all questions that inquire about specific periods of time are to be answered counting back from (and including) the actual date you sign this application.
Non-medical Questions
•
•
Have you smoked any tobacco or used tobacco or nicotine in any form (including nicotine replacement products)
or used any smoking cessation products or used hashish or marijuana in the last 12 months?
Is this insurance intended to replace, change or modify any existing life insurance policy(ies) or any life insurance policy(ies)
cancelled within the last six months (not including any employer-sponsored group policies)? If yes, please complete a
Life Insurance Replacement Declaration (LIRD).
Yes
No
Yes
No
Yes
No
If applying for Easy Access, please answer questions 1-4.
If applying for Preferred Access, please answer questions 1-10.
Easy Access® Medical Questions
1. Are you currently hospitalized or confined to a nursing care home1, OR within the last 12 months have you been
hospitalized two or more times? 1Nursing Care Home - persons confined to a residential facility, including government and independent facilities and those operated
within a hospital or retirement village, who require active daily nursing care.
2.a)Within the last two years have you been diagnosed with OR hospitalized for any of the following: stroke, heart attack,
heart surgery, heart failure (water/fluid on the lungs), angina OR: b) Within the last three years have you been diagnosed with OR hospitalized for malignant cancer
(other than basal cell carcinoma)?
Yes
No
Yes
No
3. Within the last year:
a) Have you been advised by a physician to have any of the following that has either not been completed or the results
are unknown: surgery, diagnostic testing, an investigation or a referral: b) Have you used oxygen equipment to assist in breathing?
Yes
Yes
No
No
4. Have you ever been diagnosed with, treated for, or had any indication of HIV infection or AIDS, OR
within the last five years have you been diagnosed with chronic2 kidney or liver disease or received a major organ transplant?
Yes
No
2
Chronic - A disease or condition that persists over a long period of time.
If any above question is answered with a “YES,” please provide complete details of any and all conditions including dates, diagnosis, treatment, results and
whether the condition(s) is (are) under control. (Attention Agent: If this portion of the application is to be completed, no premium is to be collected until requested
by Medavie Blue Cross.)
Remarks:
Preferred Access® Medical Questions
5. Have you ever been diagnosed with or treated for any of the following: chronic2 liver or kidney disease, organ transplant,
Alzheimer’s or Parkinson’s disease, multiple sclerosis or ALS (Lou Gehrig’s disease)?
2Chronic - A disease or condition that persists over a long period of time.
Yes
No
6. Within the last 10 years, have you been diagnosed with, treated for or hospitalized for any of the following: stroke,
heart attack, angina, heart surgery or malignant cancer (other than basal cell carcinoma)? Yes
No
7. Within the last five years, have you been diagnosed with, treated for or hospitalized for any of the following:
heart failure (water/fluid on the lungs), aneurysm, insulin diabetes, chronic obstructive lung disease
(including emphysema and chronic bronchitis), alcoholism, Crohn’s disease or ulcerative colitis? Yes
No
8. Within the last year, have you been diagnosed with, treated for or referred to a specialist for any of the following:
a) TIA (mini-stroke),
b) irregular heartbeat or irregular pulse, c) abnormal electrocardiogram (ECG),
d) abnormal blood tests or other medical tests?
Yes
No
Yes No
Yes
No
Yes
No
9. Current Height:
’
” or
cm;
Weight:
lbs or
kg.
10. Are you currently taking any prescription medication?
(If yes, please provide the following details. If you need more room, please attach a separate sheet.)
Name(s) of medication:
Reason for taking medication:
Duration of treatment:
Is the medication controlling your symptoms?
Date diagnosed with condition:
Medication
If more than three medications, indicate name(s) of additional medication(s) here:
Yes
Medication
No
Medication
6
If you’ve answered “YES” to any medical question from 1 to 4 on the previous page:
If I have answered “YES” to any one of medical questions 1 to 4 on Page 6 of this application, then I understand and agree that no coverage is in
effect until a review of the medical history has been completed, the initial premium is paid in full and a policy is issued by Medavie Inc., operating
under the business name Medavie Blue Cross, and Blue Cross Life Insurance Company of Canada.
I apply for Easy Access life insurance and declare that all answers given concerning this application and declaration are full, complete and true.
Please be advised that any incorrectly answered questions or false statements on this application or declaration may result in Blue Cross Life
Insurance Company of Canada/Medavie Blue Cross declaring the policy void. Blue Cross Life Insurance Company of Canada/Medavie Blue
Cross reserves the right to levy an expense recovery fee under these circumstances.
I am applying for Preferred Access® life insurance.
I apply for Preferred Access life insurance and declare that all answers given concerning this application and declaration are full, complete and true.
I understand and agree that this insurance is not in effect until a review of the medical history has been completed, the initial premium is paid in
full and a policy is issued by Blue Cross Life Insurance Company of Canada/Medavie Blue Cross.
If Preferred Access is declined, Easy Access will be issued based on premium received.
Please be advised that any incorrectly answered questions or false statements on this application or declaration may result in Blue Cross Life
Insurance Company of Canada/Medavie Blue Cross declaring the policy void. Blue Cross Life Insurance Company of Canada/Medavie Blue
Cross reserves the right to levy an expense recovery fee under these circumstances.
Easy Access and Preferred Access
I, the undersigned, declare the answers to the above questions are complete and accurate and form part of an application for coverage with Blue Cross
Life Insurance Company of Canada (Blue Cross Life) and/or Medavie Blue Cross. The information provided herein and collected in the future as part of
the application process will be kept confidential and secure. This information will be used to determine eligibility for coverage, to administer the terms
of my policy, to recommend suitable products and services to me and to manage the company’s business. I authorize any physician, health practitioner,
hospital, clinic, pharmacy, or other medical or medically related facility, insurance company, government or regulatory authority, or other organization,
institute or person, that has any records or knowledge of me or my health, to give Blue Cross Life, Medavie Blue Cross or their reinsurer any such
information. I further authorize Blue Cross Life and Medavie Blue Cross to disclose this information to each other, their reinsurer or to any third
party when required to determine eligibility of the application. Medical information may also be released to my personal physician or other medical
practitioner. This consent is valid for as long as the contract is in force, unless I revoke it in writing. I understand I may revoke my consent at any time;
however, if consent is withheld or revoked the coverage may be denied or rescinded. I understand why my personal information is needed and am
aware of the risks and benefits of consenting or refusing to consent. I can contact Medavie Blue Cross at 1-800-667-4511 should I have questions as to the
collection, use or disclosure of my personal information.
This consent complies with federal and provincial privacy laws. A photocopy of this consent is as valid as the original.
Signature of Policy Owner
Signature of Proposed Life Insured
Signature of Witness (other than beneficiary) Printed Name of Witness
Dated at:
on this
day of
Attending Physician’s Verification
Easy Access®
Preferred Access®
Remarks:
IMPORTANT: Verification must be substantiated by review of this person’s documented medical
history.
Date
Attending Physician’s Full Name (please print)
year
Attending Physician’s
Contact Information
I have reviewed the Proposed Life Insured’s answers to non-medical and medical questions 1 to 4 on Page 6 and to the best of my knowledge the answers given are correct.
I have reviewed the Proposed Life Insured’s answers to non-medical and medical questions 1 to 10 on Page 6
and to the best of my knowledge the answers given are correct.
(to be completed by agent)
Name:
Telephone Number:
Attending Physician’s Signature
BRO-034E 12/14
The Blue Cross symbol and name are registered trademarks of the Canadian Association of Blue Cross Plans, used under licence by Medavie Blue Cross, an independent licensee of the Canadian Association of Blue Cross Plans.
If you’ve answered “NO” to medical questions 1-4 on the previous page:
I understand and agree that, if I’ve answered “NO” to medical questions 1 to 4 on Page 6 on the date I’ve signed and dated this application, I am
eligible for insurance coverage in the amount for which I’ve applied effective immediately, provided the initial payment is paid in full, and the
attending physician’s signature, if required, confirms the “NO” answers to the medical questions.
The Easy Access and Preferred Access symbols and names are registered trademarks of Blue Cross Life Insurance Company of Canada.
I am applying for Easy Access® life insurance.
TM
®