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Health Track Insurance (Desjardins Insurace)

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06063E (2020-03)
I wish to:
Enrol in the insurance
Change my insurance
DOCUMENTS SENT ON:
YYYY MM DD
INSURANCE CONTRACT ADMINISTRATION
FINANCIAL SERVICES INCLUDING INSURANCE,
ANNUITIES, CREDIT AND RELATED SERVICES
INDIVIDUAL HEALTH
INSURANCE APPLICATION
POLICY NO. E888
PLEASE READ THE BACK OF THIS FORM AND SIGN SECTION D.
IMPORTANT – Please be sure to read section E on the back of this form before completing this section.
Please check only one option:
BRONZE OPTION
SILVER OPTION
GOLD OPTION
*
Please check only one coverage:
Coverage without dependents (individual)
Coverage with dependents (family)
In order to be eligible for the optional dental care benefit, you must have answered ‘‘Yes’’ to question 2
in section A of this form. You can only enrol in the optional dental care benefit when you enrol in Health
Track Insurance. It is not possible to enrol in this benefit at a later date.
*
If you have selected the GOLD option, please read the information below and indicate your choice:
I want to enrol in the Optional dental care benefit:
Yes
No
B -
OPTION AND COVERAGE SELECTION
I authorize any entity authorized by Desjardins Financial Security Life Assurance Company (DFS), hereinafter Desjardins Insurance, such as Retraite Québec, to deduct
at the source of payment, namely from
my pension benefits, the premium amount, until further notice. I authorize Desjardins Insurance to use or communicate my social
insurance number for administrative purposes.
Signature of policyholder:
Date:
C - PAYMENT METHOD
Please select one payment method only and complete the
related section (1 or 2).
Last and first name(s) of account holder(s) Telephone No.
Name of the financial institution where the account is located
Institution No. Transit/branch No. Account No.
• Attach a personal cheque marked ‘‘VOID’’ to avoid errors in transcription.
• If you change your account or financial institution, please advise Desjardins Insurance.
2.
PERSONAL PRE-AUTHORIZED DEBIT ENROLMENT
(
PAD
)
– PAYOR AUTHORIZATION
Please read section F on the back of this form.
YYYY MM DD
YYYY MM DD
Last name First name Health Track certificate number (for changes only)
Address - No., street, apt. City Province Postal code
Telephone number E-mail Date of birth Sex Language
M
F
E
F
Former employer Former contract number Certificate or identification No. used in the former contract
Name of previous insurer
Group coverage ended on
Coverage held with previous insurer
Individual
Family
Single-parent
Couple
Yes
No
Yes
No
Yes
No
A - IDENTIFICATION OF POLICYHOLDER Please print.
IMPORTANT - If Desjardins Insurance was not your previous insurer, please submit evidence of your previous coverage and its end date.
C P 3000
Lévis Québec G 6 V 9 X 8
Telephone number 1 8 7 7 6 4 7 5 2 3 5
Fax number 4 1 8 8 3 3 7 0 5 1 or 1 8 6 6 8 3 3 7 0 5 1
desjardins life insurance dot com slash plan member
Desjardins Insurance Life Health Retirement logo
1. Did you have extended healthcare coverage under your group insurance plan?
2. Did you have dental care coverage under your group insurance plan?
3. Were you actively at work when your group coverage ended?
OPTION
SELECTION
COVERAGE
SELECTION
1.
AUTHORIZATION FOR DEDUCTION AT SOURCE
Please provide your social insurance number
:
WITHDRAWAL AUTHORIZATION
I authorize Desjardins Insurance to make monthly pre-authorized debits (PAD) from my account with the aforementioned financial institution. Each withdrawal will
correspond to a variable amount. I will receive pre-notification of this variable amount from Desjardins Insurance no later than the date the premium is scheduled to be
withdrawn. Consequently, I hereby waive my right to be sent this pre-notification within the 10-day period set out under Payments Canada’s Rule H1. I further
waive my right to receive any pre-notification as long as the withdrawal amount remains the same or when changes are made to my personal coverage at
my request. I hereby acknowledge having received a copy of this Agreement. I acknowledge having read the ADDITIONAL PROVISIONS INCLUDED IN THE PAYOR
AUTHORIZATION in section F on the back of this form.
CONSENT TO DISCLOSURE OF INFORMATION
I hereby consent to the disclosure of the information contained in my pre-authorized debit enrolment agreement to the financial institution, provided such information is
directly related to and required for the smooth application of the rules governing pre-authorized debits.
Signature of account holder
Date
Signature of a second account holder (Only if two signatures are required)
Date
Health Track Insurance
®
C. P. 3000
Lévis (Québec) G6V 9X8
Tel.: 1-877-647-5235
Fax: 418-833-7051 or 1-866-833-7051
desjardinslifeinsurance.com/planmember
PRINT
NEW REQUEST
I certify that all the information provided herein is complete and true. I acknowledge having read the comparative table, the rate leaflet, the Take the next
step with Health Track Insurance brochure and am aware of the options available to me. I acknowledge that all the benefits offered in the policy are subject
to the provisions for limitations or reductions as well as to the exclusions stipulated therein.
I authorize Desjardins Insurance, its agents and service providers
to collect, use and disclose information about me, my spouse or my dependents to any person or organization including the pharmacies, health care
practitioners, institutions, investigative agencies or insurers for the purposes of underwriting, administration, optimal health management, auditing and paying
claims.
My policy will be sent to me once the insurer has received my individual health insurance application. I understand that I will have 10 days from the
date I receive the policy to cancel it. I acknowledge having read the information appearing on this form and have kept a copy of the form. A photocopy of
this authorization is as valid as the original.
Signature of policyholder: Date:
PLEASE SEND THE ORIGINAL TO DESJARDINS INSURANCE AND KEEP A COPY FOR YOUR FILE.
Desjardins Insurance handles the personal information it has on you in a confidential manner. Desjardins Insurance keeps this information on file so that you
may benefit from the Company’s various financial services (insurance, annuities, credit, etc.). This information is consulted solely by Desjardins Insurance
employees who need to do so in the course of their work. Desjardins Insurance may compile anonymized personal information for statistical and informational
purposes. Desjardins Insurance may also communicate with plan members to provide them with optimal health management. You have the right to consult
your file. You may also have information corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a
written request to the following address: Privacy Officer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance
may send information on its promotions or offer new products to those whose names appear on its client list. If you do not wish to receive these offers, you
may have your name removed from the list. To do so, you must send a written request to the Privacy Officer at Desjardins Insurance.
G - PERSONAL INFORMATION MANAGEMENT
I have certain recourse rights if any debit does not comply with this Agreement. For example, I have the right to receive reimbursement for any debit that is
not authorized or is not consistent with this PAD Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit
www.payments.ca. The financial institution shall reimburse me, on behalf of the organization, for any amounts withdrawn in error, within 90 calendar days of
the withdrawal, provided that the reimbursement is claimed for a valid reason. I understand that a claim to this effect must be made to my financial institution
following the procedure it will provide for that purpose. Finally, I acknowledge that a claim for reimbursement filed after the aforementioned time limits must be
settled between me and Desjardins Insurance, without any liability or commitment on the part of my financial institution.
REIMBURSEMENT
I shall inform Desjardins Insurance in a timely manner, of any changes to this Agreement. I retain the right to revoke my authorization at any time, with a
pre-notification of 30 calendar days. To obtain a sample of the cancellation form or for more information on my right to cancel a PAD Agreement, I may contact
my financial institution or visit Payments Canada Web site at payments.ca.
I agree to release the financial institution of any liability if the revocation is not respected, except in the case of gross negligence on its part. I agree that the
financial institution at which I maintain the account is not required to verify that the payment is debited in accordance with this authorization. I also certify that
every person whose signature is required for the operation of the aforementioned account has signed this authorization. I acknowledge that the delivery of this
authorization to Desjardins Insurances constitutes delivery by me to the aforementioned financial institution.
CHANGE OR CANCELLATION
F - PERSONAL PRE-AUTHORIZED DEBIT ENROLMENT (PAD)
ADDITIONAL PROVISIONS INCLUDED IN THE PAYOR AUTHORIZATION
• If you were enrolled in family, single-parent or couple coverage under your group insurance plan, you may choose either the Coverage without
dependents (individual) or the Coverage with dependents (family).
• If you were enrolled in individual coverage under your group insurance plan, you can only choose Coverage without dependents (individual).
COVERAGE SELECTION RULES
• You may increase your coverage at any time by selecting an option with more comprehensive benefits than what you already have.
• You must keep the same option for 36 months before you can reduce your coverage or as a result of a life event.
• You must keep the optional dental care benefit for 36 months before you can cancel it.
OPTION CHANGE RULES
E -
OPTION CHANGE AND COVERAGE SELECTION RULES
D - DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
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Completed 9 February 2021

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