(Please Print)
Policyholder Name Policy Number Division Number
Plan Member’s Name Certificate Number
Child’s Name Date of Birth (mm/dd/yyyy)
Please check the applicable box, provide the necessary information, and sign below. If you have any questions regarding the completion
of this form or coverage, please contact your Group Plan Administrator.
£ FULL-TIME STUDENT
A child who is in full-time attendance at an accredited post-secondary educational institution (College or University) may continue coverage if
they are under the Maximum Age for Dependent Children in the Schedule of Benefits. They must continue to meet the definition of an eligible
dependent according to the Group Policy. Some conditions include that they be unmarried, have provincial health care coverage in the
province of residence, and not be engaged in any work on a full-time basis. Coverage for students attending school outside of their home
province will be restricted.
Coverage will terminate at the earlier of withdrawal from classes or when the student reaches the maximum age for an Overage
Dependent under the terms of the Group Policy. Coverage for continuing students will be without disruption during breaks between terms.
Name of College or University Expected Completion Date
of Schooling (mm/dd/yyyy)
Is the College or University within Canada?
£ Yes £ No - If College or University is outside of Canada, please attach documentation
providing proof of enrolment
Note: We recommend the member contact his/her Provincial Health Insurance Plan to confirm that coverage will continue for the student while
studying outside of Canada. The Provincial Plan may require additional documentation and may need to approve coverage prior to the student
leaving the country.
£ DISABLED CHILD
An unmarried child who was insured prior to age 21 as an eligible dependent of an insured employee may remain an eligible dependent
if they were, prior to age 21, and continue to be, both incapable of self-sustaining employment by reason of a developmental or physical
disability, and are chiefly dependent upon the insured employee for support and maintenance. Coverage must be applied for prior to the
child’s 21st birthday.
Satisfactory proof in the form of a letter from the child’s attending physician that the conditions specified above exist must be attached to
this application.
I certify that the named child meets the above applicable conditions.
Plan Member’s Signature
Date
441(2020/08/21) Page 1 of 1
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
APPLICATION FOR COVERAGE OF DEPENDENT CHILD OVER AGE 21
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.265.4556 T 519.886.5210 F 519.88 3.740 3
www.equitable.ca
