Fillable Evidence of Insurability (RTIP/ARM) Application for Insurance and (OTIP RAEO)

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Evidence of Insurability (RTIP/ARM) Application for Insurance and (OTIP RAEO)

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The Evidence of Insurability (RTIP/ARM) Application for Insurance and (OTIP RAEO) form is 3 pages long and contains:

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  • 46 check-boxes
  • 249 other fields

Country of origin: CANADA
File type: PDF

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Page 1 of 3
EOI_RTIP OTIP 10/16
Application for Insurance and
Evidence of Insurability
(RTIP/ARM)
OTIP
125 Northfield Drive West
PO Box 218
Waterloo ON N2J 3Z9
1.800.267.6847 | www.otip.com
IMPORTANT: (Please print all answers)
1. Check (a ) the appropriate box to indicate the type of coverage for which you are applying.
PLAN MEMBER ONLY PLAN MEMBER AND SPOUSE PLAN MEMBER, SPOUSE AND DEPENDANTS SPOUSE AND/OR DEPENDANTS
2. Please ensure that ALL SECTIONS are completed.
3. If required, retain a copy for your files.
Late entrant Increase in coverage
Extended health care coverage: Single Family Dependant
®
Plan Member Name (First, Middle Initial and Last) Gender
Male Female
Province Postal Code
City/TownAddress (Number, Street and Apt.)
Home Telephone Number
OTIP ID Number Plan/Policy Number Email Address
Work Telephone Number Date of Birth (mm/dd/yyyy)
Section 1: MeMber bASic PerSonAL inForMAtion
Plan Member’s Name (First, Middle Initial and Last)
Spouse’s Name (First, Middle Initial and Last)
Height
––––––––––– m ––––––––––– cm
––––––––––– ft ––––––––––– in
Height
––––––––––– m ––––––––––– cm
––––––––––– ft ––––––––––– in
Weight
––––––––––– kg ––––––––––– lbs
Weight
––––––––––– kg ––––––––––– lbs
Have you smoked (cigarettes, cigars, pipe, etc.) or used tobacco in any other form
within the last 12 months?
Yes No
Have you smoked (cigarettes, cigars, pipe, etc.) or used tobacco in any other form
within the last 12 months?
Yes No
Have you lost or gained more than 10 lbs during the last 12 months?
Yes No If “Yes,” please answer the following:
Sex
Male Female
Date of Birth (mm/dd/yyyy)
Have you lost or gained more than 10 lbs during the last 12 months?
Yes No If “Yes,” please answer the following:
Reason For Weight Loss/Gain?
Reason for weight loss/gain
Is the Name of Personal Physician the same as the member’s?
Yes No If “No,” please provide.
Name of Personal Physician (First, Middle Initial and Last)
Address of Personal Physician (Number, Street and Apt.)
City/Town
Physician’s Telephone Number
What was the amount of weight change?
–––––––––––––– kg –––––––––––––– lbs
Home Telephone Number
What was the amount of weight change?
–––––––––––––– kg –––––––––––––– lbs
Was this a gain or a loss?
Work Telephone Number
Was this a gain or a loss?
Province Postal Code
Name of Personal Physician (First, Middle Initial and Last)
Address of Personal Physician (Number, Street and Apt.)
City/Town
Physician’s Telephone Number
Province Postal Code
Section 2: MeMber beneFitS (PLeASe cHecK tHe beneFit(S) YoU Are APPLYinG For)
Section 3: PLAn MeMber inForMAtion
Section 4: SPoUSe inForMAtion (to be coMPLeted iF APPLYinG coverAGe For SPoUSe.)
Page 2 of 3
EOI_RTIP OTIP 10/16
Please provide the following information for each dependant to be insured.
To be completed when dependants are applying for coverage.
Name of Dependant’s Personal Physician (First, Middle Initial and Last)
Address of Personal Physician (Number, Street and Apt.)
I confirm that the above member and dependants are currently enrolled in a provincial health plan, e.g. OHIP.
Yes No
Complete Name of Eligible Dependant
Gender
Currently a
full-time
student?
Relationship to
Plan Member
Date of Birth
(mm/dd/yyyy)
Height
Weight
Physician’s Telephone Number
Province Postal Code
m cm
ft in
kg lbs
Male
Female
Yes
No
Male
Female
Yes
No
Male
Female
Yes
No
Male
Female
Yes
No
City/Town
Section 5: dePendAnt StAteMent
COMPLETE ALL QUESTIONS BELOW on behalf of ALL applicants. Provide full details to ALL YES QUESTIONS.
If you require more room for YES answers, please attach a separate sheet (signed and dated).
1. During the past 12 months have you:
(a) flown as a pilot, student pilot or crew member or have any intention of doing so?
Yes No Yes No Yes No
2. Have you:
(a) ever applied for or received benefits, compensation or pension because of sickness or injury?
Yes No Yes No Yes No
3. Have you ever consulted a physician for, ever been treated for or had any known identification of:
(a) chest pain, blood vessel disease, heart disorder or heart attack or stroke? Yes No Yes No Yes No
(b) engaged in racing, underwater diving, parachuting or any other hazardous sport or have any intention
Yes No Yes No Yes No
of doing so?
(b) high blood pressure?
Yes No Yes No Yes No
(c) allergies or skin disorders, including growths, cysts or tumours? Yes No Yes No Yes No
(d) glandular disorders, including thyroid disorders and diabetes? Yes No Yes No Yes No
(e) epilepsy, neurological disorder (e.g., Multiple Sclerosis, Parkinson’s)? Yes No Yes No Yes No
(f) nervous or mental disorder or an emotional condition such as anxiety or depression? Yes No Yes No Yes No
(g) excessive use of alcohol or drugs? Yes No Yes No Yes No
(h) lung disorders? Yes No Yes No Yes No
(i) bowel, stomach or liver disorders? Yes No Yes No Yes No
(j) cancer? Yes No Yes No Yes No
(k) disorder of the kidney, urine or genital organs? Yes No Yes No Yes No
(l) arthritis, rheumatism or fibromyalgia? Yes No Yes No Yes No
(m) disorders of the muscles or bones including the back, spine or joints? Yes No Yes No Yes No
(b) ever had an application for life or health insurance declined, postponed or modified in any way?
Yes No Yes No Yes No
(c) been absent from work for medical reasons during the last 5 years? Yes No Yes No Yes No
(d) recently received any treatment/medications? Yes No Yes No Yes No
(e) any condition which might require medical consultation, hospitalization or future surgical or Yes No Yes No Yes No
psychiatric treatment?
(f) any family history of any inherited or familial disease (e.g. Huntington’s Chorea, diabetes, heart or Yes No Yes No Yes No
kidney disease)
(n) immune deficiency disorder including AIDS or AIDS-related complex (ARC) or any generalized
enlargement of the lymph glands or any test results indicating possible exposure to the AIDS
(e.g. HTLV-III, LAV) virus?
(o) anemia, or other blood disorders? Yes No Yes No Yes No
Plan Member Spouse Dependant(s)
Section 6: MedicAL qUeStionS For ProPoSed inSUred
Yes No Yes No
Yes No
4. Have you ever had any physical impairment, condition, disease or disorder or chronic symptoms including
Chronic Fatigue Syndrome or chronic pain not covered above?
Yes No Yes No Yes No
Page 3 of 3
EOI_RTIP OTIP 10/16
Question
Number
Name of Person
(First and Middle)
Details or
Name of Condition
Date and
Duration
(mm/dd/yyyy)
Treatment and Results
(Recovery/Remaining Effects)
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
information can be found in OTIP’s Privacy Policy available at www.otip.com, or the Insurer’s Privacy Policy available at www.manulife.com, or by request.
Please return all completed documentation to:
OTIP
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
limited to:
• 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.
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
Date (mm/dd/yyyy)
MAiLinG inStrUctionS
OTIP
1-800-267-6847
OTIP Benefits Services
1-866-783-6847
qUeStionS?
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Evidence of Insurability (RTIPARM) Application for Insurance and (OTIP RAEO)

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Completed 6 January 2021

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