PLAN ADMINISTRATOR
TO COMPLETE
PARTICIPANT TO COMPLETE
FV197A-CISELF (2014-06)
Email of Plan Administrator
Name (please print)
Signature of Plan Administrator
Tel. Ext.
Y M
D
Y M
D
Y M
D
05
FM
M DY
Address
First Name
Home Tel.
Work Tel.Employee No.
Gender
Date of Birth
Identication of Participant
Last Name
Town/City Province Postal Code
SSQ, INSURANCE COMPANY INC.
MEDICAL UNDERWRITING DEPARTMENT
PHONE NO.: 1-866-622-4776 • FAX NO.: 1-866-720-9640
medicalunderwriting@ssq.ca
VOLUNTARY CRITICAL ILLNESS
APPLICATION FORM
Date
Y M D
Y M D
I hereby authorize my employer to deduct from my salary the premiums required for the coverage I have selected. I authorize my employer and SSQ to use the above information, for administrative
purposes. I certify that all information on this form is true and complete to the best of my knowledge. Furthermore, I acknowledge that I have read the Personal Information Protection Notice on the
reverse and have kept a copy of this form.
Date: Signature:
Signature of Participant
Plan Administrator
Date of employment
Date of eligibility
Name of policyholder
Policy No.
Date form submitted by Participant
to Plan Administrator
Participant's guaranteed issue amount Spouse's guaranteed issue amount
I certify that all information above is true and complete.
Y M
D
Identication of Spouse
Last Name
Date of Birth
First Name Gender
SPOUSE:
By checking the non-smoker declaration box below, you (and your spouse, if applicable) are declaring that the following statement is true and complete. You also acknowledge that if you make a false declaration,
your coverage may be voided.
"Non-smoker" means a person who has not smoked any cigarettes, cigarillos, cigars, marijuana, used pipes, chewed tobacco or used any nicotine products (patch, gum, etc.) within the past 12 months.
Non-smoker’s declaration
Non-smokerNon-smoker
PARTICIPANT:
M F
Signature of Participant Signature of Spouse
Please check the box below which applies to this request and follow the instructions.
Application or Request for change - Increase
If your policy provides for a guaranteed issue amount and the requested amount is equal or less, you must put the coverage into
effect at the date of eligibility and deduct the premium. You do not have to notify SSQ. Please keep the form for your le.
If your policy provides for a guaranteed issue amount and the requested amount is greater, you must put into effect an
amount equal to the guaranteed issue amount at the date of eligibility and deduct the premium. In order to obtain the excess
amount of the guaranteed issue amount, please fax the form to the Medical Underwriting Department at 1-866-720-9640.
If your policy provides for a guaranteed issue amount and the proposed insured is not eligible, as he is a late applicant,
please fax the form to the Medical Underwriting Department at 1-866-720-9640.
If your policy does not provide for a guaranteed issue amount, please fax the form to the Medical Underwriting Department
at 1-866-720-9640.
If the form must be faxed to the Medical Underwriting Department
No other form is to be completed by the participant or the spouse. The Medical Underwriting Department will contact the
proposed insured directly to begin the medical underwriting process. We kindly ask you to notify your employee accordingly.
You will be informed of the decision in a decision report that will be sent to the Plan Administrator mentioned beside. If the
coverage is granted, you must put the coverage into effect at the effective date according to the policy and deduct the premium.
Request for change - Decrease
You must make the change and adjust the premium. You do not have to notify SSQ. Please keep the form for your le.
Voluntary Critical Illness Application Change
Applying for Increase Decrease
Participant
Current amount Current amount
Total amount Additional amount Withdrawn amount
Total amount Total amount
Spouse
Current amount Current amount
Total amount Additional amount Withdrawn amount
Total amount Total amount
Child(ren)
Total amount Additional amount Withdrawn amount
click to sign
signature
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