COVERAGE2GO APPLICATION FOR COVERAGE
6. TERMS AND CONDITIONS
The personal information willingly provided by me to Equitable Life, collected on this Application and held in their ﬁles, will be used by
Equitable Life for the purposes of underwriting, servicing, administration, claims processing and adjudication related to this Application,
the Coverage2go Policy and all beneﬁts under the Policy, and any supplementary documents.
I understand and authorize that for the above purposes the personal information on ﬁle is accessible to, and may be exchanged with,
authorized employees of, and relevant third parties retained by Equitable Life, participating reinsurer(s), other insurance companies, investigative
organizations, health care providers, including, but not limited to pharmacies, physicians and dentists and any other person or party whom I
authorize. If applying for my spouse and/or Dependents, I conﬁrm that I am authorized to act on their behalf and therefore this consent and
authorization also applies to the collection, use and communication of their personal information for the same purposes.
I consent to my employer/association/organization or former employer/association/organization and the current or recently ended Group
Beneﬁts Plan provider (insurance company) providing conﬁrmation of insurance coverage under the current or recently ended Group Beneﬁts
Plan for myself, my spouse and/or my Dependents.
I understand that all claims made under the Coverage2go Policy are submitted through me as the policy owner. I therefore authorize
Equitable Life to exchange information about these claims with me or any person acting on my behalf, including a spouse or Dependent, as
deemed necessary for the purposes of conﬁrming eligibility and assessing and managing the claim. I understand that all claims payments
will be deposited to the bank account provided in Section 5 of this Application.
I understand that by providing an email address, I am giving Equitable Life permission to communicate with me through email.
I understand that coverage under a policy will not become effective until my Application is approved by Equitable Life and the ﬁrst premium
payment is honoured by my ﬁnancial institution.
By checking the acknowledgement box below, you conﬁrm that the person(s) listed on this Application is/are authorized to make
withdrawals from the above account, and all terms and conditions in this Application are understood and agreed to.
All facts, statements, information and answers given on this Application are true, correct and complete. Any misrepresentation or
misstatement of any facts, statements, information or answers given and contained in this Application shall render any insurance issued in
connection with this application voidable by Equitable Life.
£ Check to conﬁrm and acknowledge your agreement with the above.
Please note: Equitable Life cannot ensure the privacy and conﬁdentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused. If you would prefer to submit your information by another means, please contact us at 1.866.963.2246.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
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