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SPECADVPYMT OTIP 06/18
I authorize the use and disclosure yearly and as required by the above-named persons.
Certification and Authorization:
I certify that the information in this form, and any further verbal or written statement provided by me in the future, is true and complete
to the best of my knowledge.
I agree that both my claim and my coverage may be denied or terminated as a result of my providing false, incomplete, or misleading
information.
I agree to repay, and direct my estate to repay, any monies that I may owe, including any applicable interest as outlined in the Group
Benets Policy to OTIP and its insurer, in accordance with the provisions of the benets plan.
I authorize OTIP as the administrator for my ELHT benets plan and its insurer to deduct such monies from my life insurance benets.
I understand that OTIP and its insurer will investigate this claim.
I authorize any person or organization who has Information pertaining to this claim, including any employer, plan administrator, plan
sponsor, health-care professional, health-care institution, pharmacy and any other medically-related facility, rehabilitation provider,
insurer, administrators of government benets or other benet programs, the Medical Information Bureau and investigative agency
(“Information”), to release and exchange Information requested by OTIP and its insurer for the purpose of administering the group plan
and assessing my claim.
I authorize OTIP, its Insurer and their reinsurers and/or service providers to collect, use, maintain, and exchange to the persons or
organizations listed above and/or each other any Information needed for the purposes of plan administration, claim assessment, audit,
investigation and management of my claim (“Purposes”).
I authorize the above collection use and exchanges of my personal information yearly and as required by the above-named parties.
I authorize the use and disclosure of my Social Insurance Number for tax reporting.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original.
I understand that OTIP’s Privacy Policy is available at www.otip.com or by request.
Claimant’s Name (please print): ___________________________________________________________________________________________
Claimant’s Signature: ________________________________________________Date: (mm/dd/yyyy) ________________________________
Any Information provided to or collected by OTIP in accordance with this authorization, will be kept in a benets health le. Access to
your Information will be limited to:
• OTIP employees, OTIP 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 Information in your le, and, where appropriate, to have any inaccurate information corrected.
APPLICATION FOR SPECIAL ADVANCE PAYMENT (CONTINUED)
