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EOI_RTIP OTIP 10/16
Name of Person
(First and Middle)
Name of Condition
Treatment and Results
Names and Addresses
of Physicians and Hospitals
If you answered “YES” to any of the questions in Section 6, please provide full details.
If more space is needed, use another form or sheet of paper (both must be signed and dated).
Section 6: MedicAL qUeStionS For ProPoSed inSUred (continUed)
Section 7: certiFicAtion And AUtHorizAtion
I certify that I (being the plan member, spouse or dependant with the capacity to contract, whichever is applicable) am applying for this beneﬁts coverage/
insurance (“Coverage”) and that the information provided for this application is true and complete. I understand that the Coverage is insured through a group
beneﬁts insurance carrier (“Insurer”). I agree that my Coverage may be denied or terminated at any time by the Insurer as a result of any false, incomplete, or
misleading information having been provided in this application. I authorize the Insurer to collect, use, maintain and disclose my personal information relevant
to this application (“Information”) for the purposes of beneﬁts plan administration, audit and the assessment, investigation, or management of this application,
and medical underwriting (collectively, the “Purposes”). I also authorize OTIP to collect, use, maintain and disclose Information for the purpose of beneﬁts plan
administration. I am authorized to consent to the collection, use, maintenance, exchange and disclosure of Information pertaining to any minor child who may be
the subject of this application for Coverage, for the Purposes, and all of the statements made herein on my own behalf shall apply equally to such minor child.
I understand that the Insurer may investigate this application and may require Information about me for the Purposes, including information regarding activities,
income, employment, education and training, health and medical history and treatment, including clinical notes. I authorize any person or organization with
Information, including any medical or health professionals, facilities or providers, professional regulatory bodies, any employer, plan administrator, plan sponsor,
insurer, investigative agency, and any administrators of other beneﬁts programs to collect, use, maintain and exchange this Information with each other, including
OTIP, the Insurer, its reinsurers and/or service providers, for the Purposes. I understand that any Coverage shall not become effective until approved by OTIP
and by the Insurer. I authorize the use of my employee number for the purposes of identiﬁcation and administration. I agree a photocopy or electronic version of
this authorization is valid. I acknowledge that more speciﬁc details regarding how and why OTIP and the Insurer collect, use, maintain, and disclose my personal
Please return all completed documentation to:
125 Northﬁeld Drive West
PO Box 218
Waterloo ON N2J 3Z9
Signature of Plan Member
Signature of Spouse (required only if evidence regarding insurability of spouse is provided in this form)
Signature of Dependant (over the age of 18)
Any Information provided to or collected by OTIP in accordance with this authorization will be kept in a beneﬁts health ﬁle. Access to your Information will be
• OTIP employees, OTIP’s representatives, OTIP’s insurer and their reinsurers and service providers in the performance of their jobs;
• Persons to whom you have granted access; and
• Persons authorized by law.
You have the right to request access to the personal information in your ﬁle, and, where appropriate, to have any inaccurate information corrected.
OTIP Beneﬁts Services