Coverage Application

* Family Name: * First Name: Middle Initial: PGY Level:

Address (Number, Street, APT. Number): City: Province: Postal Code:

Province of Employment: Program Start Date: Student ID#:

2. APPLYING FOR COVERAGE:

Health: Myself only Myself and dependants None because my partner has coverage
Dental: Myself only Myself and dependants None because my partner has coverage

If dependentchild over age 21 is a full-time student or disabled, please complete manulife formgl0514e available from the Maritime Resident Doctors office.

Partner's Date of Birth:

Do you have a Common-Law partner? Yes No
If you have a Common-Law partner, provide the date the co-habitation commenced:

3. COORDINATION OF BENEFITS:

Complete this section if you or your dependents have health and/or dental coverage under any other. benefits will be coordinated according to the industry standards.

Type of Coverage:
Spousal Health Coverage
Spousal Dental Coverage
Spousal Health Coverage Effective Date: Spousal Dental Coverage Effective Date:

Spousal Dental Coverage - Classification

Spousal Health Coverage: Your Partner Only Your Partner and Yourself Only Your Partner and Children Only Your Partner You and You Children

Spousal Dental Coverage: Your Partner Only Your Partner and Yourself Only Your Partner and Children Only Your Partner You and You Children

4. BENEFICIARY DESIGNATION FOR LIFE BENEFIT:

Failure to complete the beneficiary designation below will result in any insurance proceeds payable in the event of death to be payable to your estate.

Beneficiary's Last Name:

Beneficiary's First Name:

Beneficiary's Initial Name:

Beneficiary's Relationship:

Beneficiary's Percentage:

If you are designating a trustee/administrator, we recommend you consult with a legal advisor, and with any proposed trustee, administrator. do not complete this section if you have already, in any document, made a trustee/administrator appointment which might apply. consult first with your legal advisor.

I appoint as trusee to receive any amount due to any beneficiary under the age of majority:

5. PRIVACY INFORMATION:

At Maritime Resident Doctors,we recognize and respect the importance of privacy. when you apply for coverage, we establish a confidential file that is kept in the office of Maritime Resident Doctors we limit access to personal information in your file to the insurers/claims payers or persons authorized by Maritime Resident Doctors who require it to perform their duties, to person to whom you have granted access, and to persons authorized by law. we use the personal information to determine your eligibility for coverage and toadminister the group benefits plan.

I hereby apply for coverage under the group benefits plan issued by insurers/claims payers. i authorize the insurers/claims payers, any healthcare provider, my plan administrator, other insurance or reinsurance companies administrators of government benefits or other benefits programs, other organizations, or service providers working with Maritime Resident Doctors to exchange personal information, when necessary to determine my eligibility for coverage and to administer the plan. if applying for coverage for my partner and/or dependents, i confirm that i am authorized to act on their behalf. i agree that a photocopy or electronic copy of this authorizations and declarations section is as valid as the original. i certify that the information given is true, correct and complete to the best of my knowledge.

Enrollment or Re-enrollment Application for life, disability, health, dental and travel benefits manulife financial policy #66597-000

1. PLAN MEMBER INFORMATION:

2. APPLYING FOR COVERAGE:

3. COORDINATION OF BENEFITS:

4. BENEFICIARY DESIGNATION FOR LIFE BENEFIT:

5. PRIVACY INFORMATION: