HOW TO APPLY:
Employer: Complete the Employer Application and all document listed for Employees. If you are self-employed, you
still need to complete the Employer Application. We can complete the plan design section for you.
Employees: Each Employee must complete following:





Personal Benefits Selection - Choose Single, Couple, Family or Covered by Spouse and Disability option
Employee Enrolment - must be completed in full
Declaration of Insurability –must be completed in full
Automatic Cheque Plan (you can pay by credit card by inserting the number and expiry date)
Disclosure Agreement – Sign and date
Any missing information will delay the processing of your application. Please write legibly.
Mail all “ORIGINAL” completed forms, along with a cheque or credit card number payable to ADVANCE BENEFITS
CANADA for the first month’s premium and a cheque marked “VOID” to:
Ocean Sun Financial
109-4369 Main Street
Whistler BC, V0N 1B4
Once approved, you will be notified and you will receive
your benefits booklet and a Pay Direct drug card. Please
contact our office if you have any further questions.
---------------------------------------------------------------------------------------------------------------------------------------------------------------As your Insurance provider, it is our responsibility to ensure that you have been given the opportunity to discuss
other aspect of financial planning. Please indicate the items may be of interest to you.








Life Insurance (Is my family looked after?)
Mortgage Insurance (Am I really protected or paying too much?)
Critical Illness (to help overcome a life-threatening illness)
Child Insurance ( In case of Illness and other)
Retirement Planning (Review your current plan)
Education Savings Plan (Save for your child’s education)
Other (please indicate)_______________________________________
Waive (I have an adequate financial plan consistent with my long-term needs)
Please return this form with your application. We will contact you to discuss your options and strategies to protect
you, your family and your business.
Employee Name: ______________________________
Company Name: _______________________________
Home Phone #: ______________________________
Email Address: _______________________________
Best Time to Contact: __________________________
Jody C. Wright, Insurance Broker and Financial Advisor
109-4369 Main Street, Whistler BC V0N 1B4
604.935.4680
[email protected] or visit us at www.oceansunfinancial.com
Personal Benefit Selection
Indicate the type of benefit you require by placing an X in the appropriate box. When the form has been completed, place
the original with the Group Enrolment form and submit it to your plan administrator/rep. We will provide a more detailed
breakdown of the benefits and premiums tailored to your situation based on this information.
Employee Name: _____________________________
My dependant status is:
Single
Couple
Age:__________
Family
Annual Income:______________
Covered by Spouse
I elect the following Dental and Extended Health Benefit Program. I understand the options chosen cannot be changed
for two years from the effective date of my choice.
Optional Benefits – Choose one or both
X
Base Plan
Weekly Income
Long-Term Disability
Affordable
Plan
Simply Benefits
Beneficial
Plan
50/80/100% Pay Direct Drugs/ Nil Deductible/100% other
$25/$50 deductible 80% Basic Dental
Comprehensive
Plan
50/80/100% Pay Direct Drugs/ Nil Deductible/100% other
Nil deductible 80% Basic/50% Major Dental
Date:_________________
Employee Signature:___________________
Employer Application - Group Benefits Program
Policy #_______________ Class________ Billing Div. #__________
TPA Office Use Only
ABC Insurance Solutions Inc.
GENERAL INFORMATION
Applicant:
(Full Legal Name of Employer)
Legal Status:
 Sole Proprietor  Partnership  Corporation  Non-Profit  Other, please specify: ___________________________
Business Address:
Group Contact:
Nature of Business:
Phone Number:(
Fax Number: (
)
)
Ext. #
Email Address:
PLAN DESIGN REQUESTED
Life Insurance:  1x Annual Salary  2x Annual Salary  3x Annual Salary  Level $__________
A. D. & D. :  1x Annual Salary  2x Annual Salary  3x Annual Salary  Level $__________
Dependent Life:
 $5,000 Spouse/$2,500 Dep. Children
 $10,000 Spouse/$5,000 Dep. Children
st
th
W. I.:  15 Day / 15 Day / 17 Week
 1 Day / 8 Day / 17 Week
 1st Day / 8th Day / 26Week
W.I. Accident Only: 8th Day / 8th Day / 52 Week Benefit for  $150 per week  $200 per week  $300 per week
W.I. Benefit is for Owners Only:
 Yes  No
LTD:  120 day elimination / 5 Year Benefit (2 Yr. Own Occ.)  120 day elimination / Age 65 Benefit (2 Yr. Own Occ.)
Owners are Opting Out of Ltd.:
 Yes  No
Benefit Caps: Life $_________ AD&D $_________Weekly Indemnity $______ LTD. $ _________
Critical Illness:  Employees Only for Level $_____________  Include All Spouses for Level $ _____________
Extended Health:  Nil Ded.  $25/$50 Ded.  Dispensing Fee Ded.____/____/____% Drugs /_______% Other
Vision Care:
 Yes
 No
Nil Deductible $__________ Benefit / 24 Months
Dental:  Nil Ded.  $25/$50 Deductible / ________% Basic / ________% Major / ________% Ortho.
Employee Assistance Program:  Yes  No
REQUESTED EFFECTIVE DATE – INITIAL PREMIUM COLLECTED
Application is hereby made for a Group Benefits Plan in accordance with specifications described above. It is understood
that the agreement will not provide coverage prior to the first of the month following approval. A deposit in the amount
of $________________, equal to approximately 1 (one) month’s revenue is enclosed. Requested effective date for
coverage is _______________________ 1 st, 20_______.
Any existing coverage should not be cancelled until this application is approved.
EMPLOYEE ELIGILIBILITY / PARTICIPATION / WAITING PERIOD
Total Number of Eligible Employees __________
Number of Employees Extended Health and/or Dental:
Single _________
Family________
Waived ________
All Employees who work for the minimum of ________ Hours per Week are eligible for coverage under this plan.
(Must be at least 24 hours per week minimum to be eligible.)
Employee pays 100% of Disability premium?  Yes
 No
Employer Requests the following Cost Sharing Option: Employer pays _______% / Employee pays _______% (or)
Employer pays Health ________% Dental ________% (or) Employer pays Fixed $________ (or) _______% of salary.
Is this plan replacing an existing group benefit plan?
 Yes  No
What company? ________________________________________________________
Waiting period for new eligible employees is first of the month following _________ continuous months of employment.
(Employers may make written requests for waiting period to be waived for key employees.)
(Employees are eligible after 3 months of continuous employment. Employer may opt for 6 months.)
EMPLOYER PARTICIPATION AGREEMENT
In connection with this application, the employer:
a) declares that to the best of his knowledge, all statements, representations and answers contained herein are full,
complete and true as of the date of this application;
b) understands that coverage will not become effective until the 1 st of the month following approval and acceptance
by the insurer(s) underwriting the master group contracts and once accepted, this application will form part of the
master group contract(s);
c) acknowledges that ABC Insurance Solutions Inc. as the TPA is the Plan Administrator in all matters pertaining to
monthly premium billings, premium payments, employee enrolment, group records, employee records, insurers’
reports and client service. The Employer acknowledges that the TPA is entitled to receive fees for these services
and that such fees shall be separate and distinct from any fees, commissions, or allowances which may be received
from any insurer for services performed on its behalf;
d) understands and accepts that the authorized signature on behalf of the Employer confirms knowledge of and
consent by its proprietor, partners, directors, and/or principals that he/she/they are responsible for and personally
guarantee payment to the TPA of all premiums arising from this contract;
e) agrees to save harmless and indemnify the TPA, its shareholders, directors, officers, agents and employees and
their respective heirs, executors or assigns, from and against all claims, demands, losses damages, costs, charges
and expenses to which they may be exposed as a direct or indirect, complete or partial consequence of the
Employer, any employee of the Employer or any insurance agent acting on behalf of the Employer having
supplied inaccurate, incomplete, or false information, or failing to observe the terms of the master group
contract(s) issued to the TPA:
f) acknowledges that certain contractual and administrative conditions exist with respect to employer eligibility,
employee eligibility, employee participation, waiting period, effective dates of coverage, evidence of insurability,
pre-existing conditions and eligibility for late applicants and agree to accept and adhere to these conditions: and
g) agrees to abide by and be subject to all the terms, conditions, rules, regulation, policy particulars, definitions and
other provisions as set out in the master group contract(s) issued to the TPA, including any additions or
amendments thereto, copies of which are available to view at the office of the TPA during normal business hours.
Dated at ___________________________ in the province of __________, this_____ day of ________________, 20_____.
_________________________________________
Authorized signature of Employer
_________________________________________
Please Print Name and Title
_________________________________________
Witness Signature
_________________________________________
Please Print Name
The TPA acknowledges that the Employer participating in this application for group benefits is a client of the Agency
Identification #_________________ and that any commissions or compensation payable will be made according to the
provisions of that Agency’s Agreement.
_____________________________________________
Signature of Licensed Insurance Agent
Form 101 ER App. - cgbip (Rev’d. 03/11)
Employee Enrollment □ Reinstatement □
Policy #_______________ Class________ Cert. #_______________
TPA Office Use Only
ABC Insurance Solutions Inc.
EMPLOYER DETAILS
Name of Employer:
EMPLOYEE DETAILS
Employee Last Name:
Home Address:
First Name:
Middle Initial:
_____________________________
Apt. / Unit #
Home Phone Number: (
)
Street Address
_____________________________
City,
Prov.
Date of Birth: (Day/Month/Year)
Occupation:
Income:$______________ per _______________
(Hour, Month, Year)
If hourly, # of hrs. worked per week ___________
Family Status:
Social Insurance Number:
Email:
____________________
Postal Code
Date of Full-Time Hire / Return to Work:
(Day/Month/Year)

Do You Smoke:
Single


Yes
Married

No

Common-Law
Gender:


Divorced/Separated
Female

Male
COVERAGE INFORMATION
Requested Coverage:
 Single Coverage (Employee Only) or
 Family Coverage (Employee, Spouse, Dependents) or
 Waiver of Health (Available only if insured through Spouse’s plan)
 Waiver of Dental (Available only if insured through Spouse’s plan)
B.C. Fair PharmaCare Registration Number:
(Optional - N.B. This is not their B.C. Care Card number)
Does spouse have own coverage?

Yes

No
If yes, please complete below.
Are you and your dependent children covered under your spouse’s insurance?
Spouse’s Employer
Spouse’s Insurance Company

Yes

No
Policy Number
Spouse’s I.D. Number
DEPENDENT INFORMATION
Last Name
First Name
Middle Initial
Gender
M/F
Date of Birth
Day/Month/Year
Spouse
1st Child
2nd Child
3rd Child
4th Child
5th Child
BENEFICIARY DESIGNATION
I hereby name the following revocable (irrevocable in Quebec) beneficiary (ies) of any Life Insurance benefits payable under
this plan. If not specified, the Beneficiary will be the Estate. If any Beneficiary is a minor a Trustee should be named on
their behalf.
_________________________
Last Name
First Name/Middle Initial
_________________________
Last Name
______________________
First Name/Middle Initial
_________________________
Last Name
______________________
______________________
First Name/Middle Initial
____________________ ________%
Relationship to Employee
____________________ ________%
Relationship to Employee
____________________ ________%
Relationship to Employee
TRUSTEE FOR MINOR BENEFICIARY
I appoint ___________________________________________________ as Trustee to receive any payments on behalf of any
named Beneficiary, during his or her minority. The Trustee may apply such payments solely for the support, maintenance,
education and benefit of such a Beneficiary at the discretion of the Trustee.
SIGNATURE SECTION
I hereby apply for insurance under the group policy in force from time to time with my Employer and I hereby authorize the
required deductions (if any) from my pay and the use of my S.I.N. for the purpose of identification under the group policy if
required. Personal information contained in this application is collected and shared for the purposes of assessing risk in
underwriting. Consent is granted for the collection of additional information for the purposes of maintaining or enhancing
this insurance, record and assess claims made hereunder, ensure accuracy, completeness and that information is up-to-date.
Employee’s Signature _______________________ signed this ______day of _______________, 20___, at _____________
This Employee has been continuously employed by this Firm since this date of employment stated above and is presently
working on a permanent and fulltime basis for a minimum of 24 hours per week.
Employer’s Signature _______________________ signed this ______day of _______________, 20___, at _____________
Form 103 EE EnReIn. - cgbip (Rev’d. 03/11)
Request and Authorization for the Automatic Cheque Plan
I/We acknowledge that this authorization is provided for the benefit of ABC Insurance Solutions Inc. and my
financial institution and is provided in consideration of my financial institution agreeing to process debits
against my account in accordance with the rules of the Canadian Payments Association.
Group Policy #_______________ Firm Name _______________________________ Date _____________
I (We) warrant and guarantee that all persons whose signatures are required to sign on this account have signed this agreement below. I
(We) hereby authorize ABC Insurance Solutions Inc. to draw on my account for the following purpose(s): Business (insurance) and/or
Fund Transfer (registered retirement savings plans).
Signature of Depositor(s) ________________________________
________________________________
PRE-AUTHORIZED DEBIT AGREEMENT
1.
While the Automatic Cheque Plan is in effect, the mode of payment will be monthly and if the required monthly payments
change, a revised statement will be forwarded at least 10 calendar days before the due date to your address of record.
2.
This authorization / agreement may be cancelled at any time upon notice being provided by the payor, either in writing, or
orally with proper authorization to verify the identity of the payor, within 10 business days before the next PAD was to be issued. I (We)
acknowledge that, in order to revoke this authorization, I (we) must provide notice of revocation to ABC Insurance Solutions Inc.
3.
I (We) acknowledge that by providing and delivering this authorization to ABC Insurance Solutions Inc. constitutes delivery
by me (us) to my financial institution. Any delivery of this authorization to you constitutes delivery by me (us).
4.
I (We) acknowledge that the processing member is not required to verify that a PAD has been issued in accordance with
particulars of this PAD Agreement including, but not limited to, the amount. I (We) acknowledge that the processing member is not
required to verify that any purpose of payment for which the PAD was issued has been fulfilled by the payee as a condition to honouring a
PAD issued or caused to be issued by the payee on the account drawn.
5.
Revocation of this authorization does not terminate any contract for goods or services that exists between the payor and the
payee. The Payor’s PAD Agreement applies only to the method of payment and does not otherwise have any bearing on the contract for
goods or services exchanged.
6.
A PAD may be disputed by a payor under the following conditions:
(i)
(ii)
(iii)
the PAD was not drawn in accordance with the Payor’s PAD Agreement; or
the Payor’s PAD Agreement was revoked; or
pre-notification was not received and such notification was required under the terms of the PAD Agreement.
The payor, in order to be reimbursed, acknowledges that a declaration to the effect that either (i), (ii), or (iii) took place, must
be completed and presented to the branch of the processing member holding the payor’s account up to and including 90
calendar days in the case of a personal PAD or up to and including 10 business days in the case of a business PAD, after the
date on which the PAD in dispute was posted to the payor’s account.
The payor acknowledges that a claim on the basis that the Payor’s PAD Agreement was revoked, or any other reason, is a
matter to be resolved solely between the payee and the payor when disputing any PAD after the above time set out.
Where a disputed PAD is in regards to a Funds Transfer, no recourse is provided through the clearing system. The payor
should seek reimbursement or recourse from the member payee in the event a PAD is erroneously charged to its account.
The account that ABC Insurance Solutions Inc. is authorized to draw upon is indicated below. A specimen cheque (or facsimile) if
available for this account has been marked “VOID” and attached to this authorization. I (We) undertake to inform ABC Insurance
Solutions Inc., in writing, of any change in the account information provided in this authorization prior to the next due date of the PAD.
Attach copy of Void Cheque here.
(This Agreement in accordance with Rule H1 Implemented 15/04/02.)
F 106 PAP Auth. – cgbip (01/04)
Disclosure Acknowledgement
The provision of the following information is a requirement of the Financial Institutions Act of British Columbia. Your licensed agent
is assisting you in obtaining the financial product or service indicated by a check mark in the list below. The name of the company
offering that product or service is also shown.
Type of Product or Service
Company Which Offers the Product or Service

Group Life / Disability Insurance
_________________________________________

Group EHC / Dental Insurance
_________________________________________

Group RRSP / Group Pension
_________________________________________

Employee Assistance Program
_________________________________________

Other, _____________________
_________________________________________
(Product must be indicated)
Your licensed agent has a brokerage or single case agreement under the terms of which, the agent is able to market the products and
services of a number of companies. The agent will receive a commission as a result of this transaction paid by these companies.
The Financial Institutions Act of British Columbia prohibits tied selling. Tied selling is a practice under
which a client who wants to obtain one product or service (for example, a mortgage loan), is forced to also
buy another product (for example, home owners’ insurance), from a specific company, as a condition of
getting the first product (the mortgage loan).
Your agent may use any information received from you to make you aware of other financial products and
services that may be of interest.
I confirm that I have received a copy of this Disclosure Acknowledgement from my agent,
_______________________________. I consent to the procedures regarding handling of
information described above.
Date:___________________________
Client Name:_________________________________________
Client Signature:______________________________________
Date of Application for the Product or Service indicated above:________________________
Agent Signature:_________________________________________
Date:_______________________
Your agent is recognized as an independent broker. As such, he is not compelled by the companies listed
above to place your business with them exclusively or any other similar conditions, which could bias his
recommendations to you. The product or services he provides is based upon his assessment of your stated
needs and situation.
F 102 B.C.Finc’l Discl. – cgbip (01/04)
ABC Insurance Solutions Inc.
Group Policy # ________________
Certificate # ________________
Declaration of Insurability for Group Coverage (Please Print - Ink Only & Answer ALL Questions in Detail, both pages)
EMPLOYER: ___________________________________________
EMPLOYEE NAME: ______________________________________
OCCUPATION: __________________________ EARNINGS $______ per
YEAR
MONTH
DATE OF BIRTH: ________ (mm) ________ (dd) __________ (yyyy)
WEEK
HOME ADDRESS: _________________________________, ________________ (CITY) _______ (PROV.)
GENDER:
Male
Female
# OF HOURS PER WEEK: _____
HOUR
DAYTIME PHONE #: (______) ______ - ________
_____________ (POSTAL CODE)
HEIGHT: ________ cm OR ________ ft. ________in. WEIGHT: __________ kgs. OR _________ lbs.
DATE OF FULL-TIME EMPLOYMENT: ________ (mm) ________ (dd) __________ (yyyy)
For TPA Use Only ** Do not write in this box**
DATE ELIGIBLE FOR BENEFITS:
UNISTAR POLICY #: ____________________DIV. #: ______ BENEFIT CLASS: ____
______ (mm) ______ (dd) ______ (yyyy)
BENEFIT TO BE UNDERWRITTEN
Employee Life
Short Term Disability
Long Term Disability
Critical Illness
NON-EVIDENCE
MAXIMUM
$
$
$
$
Late Entrant Application
CURRENT INSURED
BENEFIT AMOUNT
$
$
$
$
OR
OVERALL
MAXIMUM
$
$
$
$
Excess Insurance Application
NEW ELIGIBLE
INSURED AMOUNT
$______________
$______________
$______________
$______________
SECTION I: Please answer all questions completely to avoid delays in processing
1.
Within the past twelve months have you consulted a physician or any medical practitioner, been treated for, taken medication for, or
had any known indication of any of the following conditions (if yes, circle the applicable condition(s):
Chest pain or discomfort, high cholesterol or blood pressure, circulatory problems, fainting or dizziness, diabetes, hepatitis, disorder of the
stomach, ulcer, indigestion, gall bladder, neuritis, bronchitis, tuberculosis, paralysis, intestines, lungs, respiratory system, asthma, shortness
of breath, sleep apnea, disorder of the eyes (excluding near and far sightedness), ears (excluding infection that has resolved) skin (excluding
minor rash or irritation) back, neck, knees, hips, muscles, bones, joints, fibromyalgia, chronic fatigue, mental or emotional disorder, bladder,
urinary tract, prostate, breast, reproductive system, nervous system disorder, allergies, arthritis, rheumatism or been advised that a medical
test was abnormal or follow-up is required?
2. Do you have any symptoms or complaints for which you have not yet sought treatment?
3. Have you ever undergone an electrocardiogram, an X-ray, a mammography, a blood test, or any other examination?
4. Within the past 5 years have you:
Yes
No
Yes
Yes
No
No
Yes
No
Yes
No
Yes
No
Yes
No
a) been confined in a hospital or other institution, been off work, received disability or Worker’s Compensation benefits for more
than 5 days or disability pension due to an accident or illness?
5.
6.
7.
b) had an application for insurance declined, postponed, rated or modified in any way?
Have you ever consulted a physician or any medical practitioner, been treated for or any known indication of:
a)
heart or circulatory problems including heart attack, stroke, cancer or tumour, epilepsy, multiple sclerosis, disorder of the liver,
intestines, kidney, blood or immune system?
b)
drug or alcohol abuse, used amphetamines, narcotics, barbiturates, hallucinogens, or marijuana, taken drugs for other than
medicinal purposes, been advised to drink less alcohol, received treatment for drug addiction or alcoholism, or been charged with
driving while impaired?
c)
AIDS, ARC, HIV, enlargement of lymph nodes (glands), chronic diarrhea, unusual skin lesions, or unexplained infections or other
immunological disorder?
d) for any physical or mental disorder not mentioned above?
Within the last 12 months have you lost or gained any weight? If yes, please provide details: Lost Gained
If “Yes” by how much?_______ (Kgs. or Lbs.) and: Why? _________________________________________________
Is there any history in your family (father, mother, brothers, sisters) of heart disease, stroke, high cholesterol, high blood pressure,
diabetes, kidney disease, multiple sclerosis, Huntingdon’s chorea, polyposis coli, cancer, Alzheimer’s disease, Parkinson’s disease,
muscular dystrophy, motor neuron disease, or other hereditary diseases?
If the answer to question #7 is yes, please describe which illness, which family member, age at onset of the illness, current age if alive or age at death on the table provided
below. Please attach separate sheet if more space is needed.
Circle the family member
Illness(es) (if cancer: type)
Age at onset
of the illness
Age if alive
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
SPOUSE
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
CHILDREN
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
8. List all medications requiring a prescription that you or your dependents take including medications prescribed but not yet filled
(exclude birth control pills):
Name of your medication(s): __________________________________________________________________________________________
Dependent’s Name: __________________ Medication(s), dosage and frequency: __________________________________
Age at
Death
EMPLOYEE
Dependent’s Name: __________________ Medication(s), dosage and frequency: __________________________________
9. Do you or your dependents receive physiotherapy, chiropractic, massage therapy, counseling or any other non-drug treatments?
Patient’s name ___________________________ Treatment received ________________ Why? ____________________________________
Patient’s name ___________________________ Treatment received ________________ Why? ____________________________________
Patient’s name ___________________________ Treatment received ________________ Why? ____________________________________
Monthly Cost(s)
$ ___________
$ ___________
$ ___________
Monthly Cost(s)
$ ___________
$ ___________
$ ___________
ABC Insurance Solutions Inc.
Group Policy # ________________
Certificate # ________________
SECTION II
1. Do you or any of your family members have any other physical impairment or deformity or health problems or symptoms of illness or disease not listed in Section I?
(If Yes, please provide details below)
Yes
No
2. Name of address of your personal physician or any medical practitioner(s) or chiropractor consulted in the past 5 years (please indicate if none):
a) _____________________________________________________________________________________________________
b) _____________________________________________________________________________________________________
c)
_____________________________________________________________________________________________________
3. Date and reason for last consultation(s) for each of the above:
a) _____________________________________________________________________________________________________
b) _____________________________________________________________________________________________________
c) _____________________________________________________________________________________________________
4. Provide details of any medication or treatment prescribed, or advice recommended:
________________________________________________________________________________________________________
Provide details of all “Yes” answers to any questions in Section I or Section II (Please attach separate sheet if more space is needed):
Question
Number
Nature of Disorder
(Diagnosis)
Dates of
Onset & Recovery
Medication and/or
Treatment
Approximate
Monthly Cost
Attending Physician or Hospital
(name & address)
Details pertain to
the Employee,
Spouse or Child
$
$
$
$
ALL APPLICANTS MUST COMPLETE SECTION III.
SECTION III
MIB PRE-NOTICE
MIB receives personal information and the collection, use and disclosure of such information is governed by the Personal Information Protection and Electronic
Documents Act (“PIPEDA”) and provincial laws. Therefore, MIB has agreed to protect such information in a manner that is substantially similar to the Company’s
privacy and security practices, and in accordance with applicable laws. As a U.S. based company, MIB is bound by, and such personal information may be disclosed in
accordance with, applicable U.S. laws. If you have any questions about MIB’s commitment to protect the confidentiality and security of your personal information,
you may contact the MIB Privacy Department at [email protected]. Information regarding your insurability will be treated as confidential. Western Life Assurance
Company or its reinsurers may, however, make a brief report thereon to MIB, Inc., a not-for-profit membership organization of insurance companies, which operates
an information exchange on behalf of its Members. If you apply to another MIB Member company for life or health insurance coverage, or a claim for benefits is
submitted to such a company, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you, MIB will also arrange
disclosure of any information it may have in your file. If you question the accuracy of the information in MIB's file, you may contact MIB and seek a correction in
accordance with the procedures set forth in the federal Fair Credit Reporting Act.
The address of MIB’s information office is: MIB Information Office 330 University Avenue, Suite 501 Toronto, Ontario, M5G 1R7 Telephone Number: (416) 597-0590
Western Life Assurance Company or its reinsurer(s) may also release information from its file to other insurance companies to whom you may apply for life or health
insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB may be obtained on its website at www.mib.com.
Declaration and Authorization to obtain Medical Information
I hereby declare that the above answers and statements are complete and true and that any misstatements or failure to report information may be used as the
basis for rescission of this insurance, as issued to me. I understand that if the insurance applied for becomes effective, I will be subject to all the terms of the group
policy. I agree that any coverage issued in consequence of this application shall not take effect unless, on the date the insurance would have become effective, I am
actively engaged in my occupation on a full-time basis (full time is defined as 24 hours per week or more). I further agree that the insurance applied for shall not
become effective until the application is approved by the Insurance Company. I understand the information provided on this document will be treated as confidential
and is gathered for the purpose of underwriting the insurance applied for.
I further understand that additional information including medical testing, may be required as part of the underwriting process and that this information, including medical
test results, will not be shared with my employer.
I authorize Western Life Assurance Company and Unistar Special Risks Inc. or reinsurer(s) to make a brief report of my personal health information to MIB Inc. (“MIB”).
I have read and understand the MIB Pre-Notice.
I hereby authorize any physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or other organization, institution
or person that has any records or knowledge of me or my health to give to ABC Insurance Solutions Inc., Western Life Assurance Company and Unistar Special Risks Inc.,
or reinsurer(s), any and all such information about me with reference to my health and medical history and any hospitalization, advice, diagnosis, treatment, disease,
ailment or condition. A photocopy of this authorization shall be as valid as the original.
Dated at (City, Prov.)__________________________________________________ this __________ day of __________________________________, 20_________
Signature of Applicant_____________________________________________________
Form 104/105 DMFM– cgbip (Rev’d. 02/13)