Fillable COVERAGE2GO APPLICATION FOR COVERAGE (Equitable Life of Canada)

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COVERAGE2GO APPLICATION FOR COVERAGE (Equitable Life of Canada)

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  • 30 other fields

Country of origin: CANADA
File type: PDF

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Head Office
One Westmount Road North
P.O. Box 1603 Stn Waterloo, Waterloo Ontario N2J 4C7
TF 1.866.963.2246 T 519.883.74 0 9
Email coverage2go@equitable.ca
www.equitable.ca
COVERAGE2GO APPLICATION FOR COVERAGE
1. ABOUT YOU
Applicant Name (Please Print) (First, Middle, Last)
Street Address City Province Postal Code
Phone Number Email Address
Date of Birth
(MM/DD/YYYY) £ Male
£ Female
Preferred Language:
£ English £ French
To be eligible for Coverage2go without any medical questions, you must apply within 60 days of your Group Benefits plan coverage
ending. If you apply between 61 and 90 days after your Group Benefits plan coverage ends, you will be required to complete a medical
questionnaire to determine your eligibility. You will not be eligible for Coverage2go if you apply more than 90 days after your Group
Benefit plan coverage ends.
a) Employer Name:
b) Name of Group Benefits Insurance Company:
c) Policy Number:
d) Your Termination Date from the Plan (Last Day of Coverage)
e) Previous Group Benefits Plan:
£ Health Benefits £ Dental Benefits
f) Dependent coverage with previous Group Benefits Plan?:
£ Yes £ No
2. YOUR DEPENDENTS
Children age 21 or older must be registered as a Full Time student or qualify as a Disabled Dependent.
Full Name of Spouse or Partner (Common-Law): (First, Middle, Last)
£ Male
£ Female
Date of Birth (MM/DD/YYYY):
Full Name of Child: (First, Middle, Last)
£ Male
£ Female
Date of Birth:
(MM/DD/YYYY)
£ Disabled or
£ Full Time
Student
Full Name of Child: (First, Middle, Last)
£ Male
£ Female
Date of Birth:
(MM/DD/YYYY)
£ Disabled or
£ Full Time
Student
Full Name of Child: (First, Middle, Last)
£ Male
£ Female
Date of Birth:
(MM/DD/YYYY)
£ Disabled or
£ Full Time
Student
Full Name of Child: (First, Middle, Last)
£ Male
£ Female
Date of Birth:
(MM/DD/YYYY)
£ Disabled or
£ Full Time
Student
Full Name of Child: (First, Middle, Last)
£ Male
£ Female
Date of Birth:
(MM/DD/YYYY)
£ Disabled or
£ Full Time
Student
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
573(2020/06/30) Page 1 of 3
Cheque No. Transit No.
Bank No.
Account No.
COVERAGE2GO APPLICATION FOR COVERAGE
3. CONFIRMATION OF PROVINCIAL HEALTH COVERAGE (E.G. OHIP)
You and your dependents must be covered by your provincial health plan (e.g. OHIP, AHIP, MSP) to be eligible for Coverage2go.
*
Residents of British Columbia, Manitoba and Saskatchewan MUST submit a copy of their Provincial Ministry Letter
to provide proof that you (and dependents) have registered for Provincial Drug Coverage. This documentation is required to ensure you (and
your dependents) have access to the maximum prescription drug coverage available.
If not registered, you must register for the Provincial Drug Coverage Program and attach a copy of the Provincial Ministry letters or documents
that provide proof of registration.
*
Quebec residents are not eligible for Coverage2go
4. YOUR OPTIONS
I am applying for:
£ Coverage2go
®
£ Coverage2go with Dental £ Coverage2go+ £ Coverage2go+ with Dental
5. PREMIUM PAYMENT INFORMATION, AUTHORIZATION, AND CLAIM PAYMENTS
I authorize Equitable Life to deposit Group Claim payments directly into my bank account.
Bank Name
Bank’s Transit Number (5 digits) Bank Number (3 digits)
Account Number (5-12 digits)
Start of Insurance Coverage
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.
Pre-Authorized Debit (“PAD”) for the First and Subsequent Premium Payments
Equitable Life and my financial institution are directed and authorized to process withdrawals from my bank account indicated above for the
initial premium payment and for each subsequent premium payment, on a monthly basis, subject to the conditions below, on the closest date
prior to the effective date of coverage. Your exact withdrawal date will be provided in your welcome notification once your plan has
been set up.
Where the withdrawal date occurs on a weekend or holiday, the withdrawal will be made the next business day.
Note: In the event of non-payment due to insufficient funds, an attempt to re-draw your payment will automatically occur within 2 – 10
business days from the withdrawal date. You are responsible for any NSF charges incurred by your financial institution.
I waive the right to receive pre-notification of the first withdrawal, any increases in the fixed amount of the withdrawal or a change in
the date of the withdrawal.
For the purposes of this agreement, all PAD withdrawals from this bank account will be treated as personal withdrawals of insurance
premiums, as defined by the Canadian Payments Association in Rule H1 at www.payments.ca.
Contact your financial institution about your rights regarding cancellation. I have the right to cancel this PAD at any time. This PAD shall remain
in effect until I notify Equitable Life of cancellation. Note: To ensure cancellation of the next withdrawal, notice by way of telephone, letter,
email or fax must be received at Equitable Life’s Head Office 10 business days prior to the next withdrawal. Any cancellation of this PAD
will not affect the policy contract between you and Equitable Life so long as payment is provided by an alternate method within the period
specified in your policy contract.
Claim Payments
All claim payments will be deposited to the above account.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
573(2020/06/30) Page 2 of 3
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.
Date:
MM/DD/YYYY
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
573(2020/06/30) Page 3 of 3
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COVERAGE2GO APPLICATION FOR COVERAGE (Equitable Life of Canada)

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Completed 1 March 2021

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