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PHDLPAD OTIP 09/16
Pre-authorized Debit (PAD)
Payment
oTIP Benefits Services
125 Northfield Drive West
PO Box 218
Waterloo ON N2J 3Z9
1.866.783.6847 | www.otip.com
Signature of Account holder(s) Date (mm/dd/yyyy)
IMPoRTANT: (Please print all answers)
1. Please complete ALL SECTIONS and sign the authorization section below. If you completed Section 3, you do not need to enclose a “VOID” cheque.
2. You can mail this completed form to OTIP Benefits Services or fax it to 1-866-404-6847.
3. Your first withdrawal will include your current month’s premium and if applicable, any unpaid premiums dating back to your coverage effective date.
4. If required, retain a photocopy for your files.
Plan Member Name (First, Middle Initial and Last)
Province Postal Code
City/Town
Address (Number, Street and Apt.)
Home Telephone Number
Plan Number
Email AddressWork Telephone Number
Plan Sponsor
OTIP Identification/Certificate Number
SECTION 1: MEMBER BASIC PERSONAL INFORMATION
SECTION 2: PAYOR INFORMATION ( Check this box if information is the same as above)
Payor’s Name (If different from above)
Province Postal Code
City/TownAddress (Number, Street and Apt.)
Home Telephone Number Email AddressWork Telephone Number
Financial Institution Number
Account Type
Chequing Savings
Transit Number
SECTION 3: FINANCIAL ACCOUNT INFORMATION (No void cheque is required if this section is completed.)
Account Number
Definitions: “Business Day” means any day except Saturday, Sunday or any other day when financial institutions are generally closed for the transaction of
business in the Province of Ontario.
1. I (the “Payor”) hereby authorize OTIP/RAEO Benefits Incorporated (“OTIP”) to withdraw monthly premium payments (“Personal PAD”) from my account on the
10th day of the month (or next business day) as well as any revised payment amounts or any other amounts that may be due and owing by me.
2. If my payment is returned by my financial institution, for any reason, not limited to non-sufficient funds, I understand that a $25 OTIP administration fee for
each payment returned may be added to the outstanding balance owed.
3. If my payment is returned or stopped, I understand that I will be notified and any outstanding amounts (including the $25 OTIP admin fee per returned
payment) will be automatically withdrawn from my account the following month.
4. OTIP may terminate coverage should a withdrawal be refused for any reason and the financial institution shall in no way be held liable for non-payment of
premiums should such an event occur.
5. I understand and accept that premium amounts are subject to changes made to the overall group insurance policies, or due to changes I elect and that OTIP
will automatically apply and deduct the new premium amount from my account and I agree to waive any other notice of premium changes. I acknowledge that I
can log in to the secure OTIP website (www.otip.com) to confirm my premium payments.
6. This authorization shall remain valid unless cancelled by me in writing to OTIP at least ten (10) business days prior to the next Personal PAD from my account.
I understand that cancellation of this authorization does not relieve me of my obligation to pay all amounts that may be owing to OTIP by a method of payment
that is satisfactory to OTIP.
7. 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 withdrawal
paid to OTIP that is not authorized or is not consistent with this PAD agreement. To obtain more information about my recourse rights, I may contact my financial
institution or visit www.cdnpay.ca.
8. I warrant OTIP on a continuing basis that all persons authorized to sign on this Personal PAD Account have authorized this agreement, agreed to all terms
therein and that the information provided with regard to this Personal PAD Account is accurate and complete.
9. I undertake to notify OTIP through the secure OTIP website (www.otip.com) of any changes to my chequing/savings account information, including change of
name, at least ten (10) business days prior to the the next Personal PAD from my account to ensure changes take effect.
SECTION 4: PRE-AUTHORIZED DEBIT PAYMENT AUTHORIZATION
