Document 199350

Employer: Complete the Employer Application and all document listed for Employees. If you are self-employed, you
still need to complete the Employer Application. We can complete the plan design section for you.
Employees: Each Employee must complete following:
Personal Benefits Selection - Choose Single, Couple, Family or Covered by Spouse and Disability option
Employee Enrolment - must be completed in full
Declaration of Insurability –must be completed in full
Automatic Cheque Plan (you can pay by credit card by inserting the number and expiry date)
Disclosure Agreement – Sign and date
Any missing information will delay the processing of your application. Please write legibly.
Mail all “ORIGINAL” completed forms, along with a cheque or credit card number payable to ADVANCE BENEFITS
CANADA for the first month’s premium and a cheque marked “VOID” to:
Ocean Sun Financial
109-4369 Main Street
Whistler BC, V0N 1B4
Once approved, you will be notified and you will receive
your benefits booklet and a Pay Direct drug card. Please
contact our office if you have any further questions.
---------------------------------------------------------------------------------------------------------------------------------------------------------------As your Insurance provider, it is our responsibility to ensure that you have been given the opportunity to discuss
other aspect of financial planning. Please indicate the items may be of interest to you.
Life Insurance (Is my family looked after?)
Mortgage Insurance (Am I really protected or paying too much?)
Critical Illness (to help overcome a life-threatening illness)
Child Insurance ( In case of Illness and other)
Retirement Planning (Review your current plan)
Education Savings Plan (Save for your child’s education)
Other (please indicate)_______________________________________
Waive (I have an adequate financial plan consistent with my long-term needs)
Please return this form with your application. We will contact you to discuss your options and strategies to protect
you, your family and your business.
Employee Name: ______________________________
Company Name: _______________________________
Home Phone #: ______________________________
Email Address: _______________________________
Best Time to Contact: __________________________
Jody C. Wright, Insurance Broker and Financial Advisor
109-4369 Main Street, Whistler BC V0N 1B4
[email protected] or visit us at
Personal Benefit Selection
Indicate the type of benefit you require by placing an X in the appropriate box. When the form has been completed, place
the original with the Group Enrolment form and submit it to your plan administrator/rep. We will provide a more detailed
breakdown of the benefits and premiums tailored to your situation based on this information.
Employee Name: _____________________________
My dependant status is:
Annual Income:______________
Covered by Spouse
I elect the following Dental and Extended Health Benefit Program. I understand the options chosen cannot be changed
for two years from the effective date of my choice.
Optional Benefits – Choose one or both
Base Plan
Weekly Income
Long-Term Disability
Simply Benefits
50/80/100% Pay Direct Drugs/ Nil Deductible/100% other
$25/$50 deductible 80% Basic Dental
50/80/100% Pay Direct Drugs/ Nil Deductible/100% other
Nil deductible 80% Basic/50% Major Dental
Employee Signature:___________________
Employer Application - Group Benefits Program
Canadian Group Benefit Insurance Programs
Policy #_______________ Class________ Billing Div. #__________
TPA Office Use Only
(Full Legal Name of Employer)
Legal Status:
Sole Proprietor
Other, please specify: ___________________________
Business Address:
Group Contact:
Nature of Business:
Phone Number:(
Fax Number: (
Ext. #
Email Address:
Life Insurance: 1x Annual Salary
2x Annual Salary
3x Annual Salary
Level $__________
A. D. & D. :
1x Annual Salary
2x Annual Salary
3x Annual Salary
Level $__________
Dependent Life:
$5,000 Spouse/$2,500 Dep. Children
$10,000 Spouse/$5,000 Dep. Children
W. I.: 15 Day / 15 Day / 17 Week
1 Day / 8 Day / 17 Week
1st Day / 8th Day / 26Week
W.I. Accident Only: 8th Day / 8th Day / 52 Week Benefit for $150 per week
$200 per week
$300 per week
W.I. Benefit is for Owners Only:
120 day elimination / 5 Year Benefit (2 Yr. Own Occ.)
120 day elimination / Age 65 Benefit (2 Yr. Own Occ.)
Owners are Opting Out of Ltd.:
Benefit Caps: Life $_________ AD&D $_________Weekly Indemnity $______ LTD. $ _________
Critical Illness:
Employees Only for Level $_____________
Include All Spouses for Level $ _____________
Employees Level $__________
Spouses Level $__________
Children Level $__________
Extended Health:
Nil Ded.
$25/$50 Ded.
Dispensing Fee Ded.____/____/____% Drugs /_______% Other
Vision Care:
Nil Deductible $__________ Benefit / 24 Months
Nil Ded.
$25/$50 Deductible / ________% Basic / ________% Major / ________% Ortho.
Employee Assistance Program:
Application is hereby made for a Group Benefits Plan in accordance with specifications described above. It is understood
that the agreement will not provide coverage prior to the first of the month following approval. A deposit in the amount
of $________________, equal to approximately 1 (one) month’s revenue is enclosed. Requested effective date for
coverage is _______________________ 1st, 20_______.
Any existing coverage should not be cancelled until this application is approved.
Total Number of Eligible Employees __________
Number of Employees Extended Health and/or Dental: Single _________ Family________ Waived ________
All Employees who work for the minimum of ________ Hours per Week are eligible for coverage under this plan.
(Must be at least 24 hours per week minimum to be eligible.)
Employee pays 100% of Disability premium?
Employer Requests the following Cost Sharing Option: Employer pays _______% / Employee pays _______% (or)
Employer pays Health ________% Dental ________% (or) Employer pays Fixed $________ (or) _______% of salary.
Is this plan replacing an existing group benefit plan?
What company? ________________________________________________________
Waiting period for new eligible employees is first of the month following _________ continuous months of employment.
(Employers may make written requests for waiting period to be waived for key employees.)
(Employees are eligible after 3 months of continuous employment. Employer may opt for 6 months.)
In connection with this application, the employer:
a) declares that to the best of his knowledge, all statements, representations and answers contained herein are full,
complete and true as of the date of this application;
b) understands that coverage will not become effective until the 1st of the month following approval and acceptance
by the insurer(s) underwriting the master group contracts and once accepted, this application will form part of the
master group contract(s);
c) acknowledges that the TPA is the Plan Administrator in all matters pertaining to monthly premium billings,
premium payments, employee enrolment, group records, employee records, insurers’ reports and client service.
The Employer acknowledges that the TPA is entitled to receive fees for these services and that such fees shall be
separate and distinct from any fees, commissions, or allowances which may be received from any insurer for
services performed on its behalf;
d) understands and accepts that the authorized signature on behalf of the Employer confirms knowledge of and
consent by its proprietor, partners, directors, and/or principals that he/she/they are responsible for and personally
guarantee payment to the TPA of all premiums arising from this contract;
e) agrees to save harmless and indemnify the TPA, its shareholders, directors, officers, agents and employees and
their respective heirs, executors or assigns, from and against all claims, demands, losses damages, costs, charges
and expenses to which they may be exposed as a direct or indirect, complete or partial consequence of the
Employer, any employee of the Employer or any insurance agent acting on behalf of the Employer having
supplied inaccurate, incomplete, or false information, or failing to observe the terms of the master group
contract(s) issued to the TPA:
f) acknowledges that certain contractual and administrative conditions exist with respect to employer eligibility,
employee eligibility, employee participation, waiting period, effective dates of coverage, evidence of insurability,
pre-existing conditions and eligibility for late applicants and agree to accept and adhere to these conditions: and
g) agrees to abide by and be subject to all the terms, conditions, rules, regulation, policy particulars, definitions and
other provisions as set out in the master group contract(s) issued to the TPA, including any additions or
amendments thereto, copies of which are available to view at the office of the TPA during normal business hours.
Dated at ___________________________ in the province of __________, this_____ day of ________________, 20_____.
Authorized signature of Employer
Witness Signature
Please Print Name and Title
Please Print Name
The TPA acknowledges that the Employer participating in this application for group benefits is a client of the Agency
Identification #_________________ and that any commissions or compensation payable will be made according to the
provisions of that Agency’s Agreement.
Hollett Holdings Inc. 401-1630 Pandosy Street Kelowna B.C V1Y 1P7
Signature of Licensed Insurance Agent
Employee Enrollment □ Reinstatement □
Policy #_______________ Class________ Cert. #_______________
TPA Office Use Only
Canadian Group Benefit Insurance Programs
Name of Employer:
Employee Last Name:
Home Address:
First Name:
Middle Initial:
Date of Birth: (Day/Month/Year)
Income:$______________ per _______________
(Hour, Month, Year)
If hourly, # of hrs. worked per week _________
Family Status:
Social Insurance Number:
Home Phone Number: (
Date of Hire / Return to Work:
Do You Smoke:
Requested Coverage:
Single Coverage (Employee Only) or
Family Coverage (Employee, Spouse, Dependents) or
Does spouse have own coverage?
Waiver of Health (Available only if insured through Spouse’s plan)
Waiver of Dental (Available only if insured through Spouse’s plan)
If yes, please complete below.
Are you and your dependent children covered under your spouse’s insurance?
Spouse’s Employer
Spouse’s Insurance Company
Policy Number
Spouse’s I.D. Number
Last Name
First Name
Middle Initial
Date of Birth
1st Child
2nd Child
3rd Child
4th Child
5th Child
I hereby name the following revocable (irrevocable in Quebec) beneficiary (ies) of any Life Insurance benefits payable under
this plan. If not specified, the Beneficiary will be the Estate. If any Beneficiary is a minor a Trustee should be named on
their behalf.
Last Name
First Name/Middle Initial
Last Name
First Name/Middle Initial
Last Name
First Name/Middle Initial
____________________ ________%
Relationship to Employee
____________________ ________%
Relationship to Employee
____________________ ________%
Relationship to Employee
I appoint ___________________________________________________ as Trustee to receive any payments on behalf of any
named Beneficiary, during his or her minority. The Trustee may apply such payments solely for the support, maintenance,
education and benefit of such a Beneficiary at the discretion of the Trustee.
I hereby apply for insurance under the group policy in force from time to time with my Employer and I hereby authorize the
required deductions (if any) from my pay and the use of my S.I.N. for the purpose of identification under the group policy if
required. Personal information contained in this application is collected and shared for the purposes of assessing risk in
underwriting. Consent is granted for the collection of additional information for the purposes of maintaining or enhancing
this insurance, assess claims made hereunder, ensure accuracy, completeness and that information is up-to-date.
Employee’s Signature _______________________ signed this ______day of _______________, 20___, at _____________
This Employee has been continuously employed by this Firm since this date of employment stated above and is presently
working on a permanent and fulltime basis for a minimum of 20 hours per week.
Employer’s Signature _______________________ signed this ______day of _______________, 20___, at _____________
Form 103 EE EnReIn. - cgbip (Rev’d. 01/04)
Declaration of Insurability
Canadian Group Benefit Insurance Programs
Group # _______________
Certificate # _______________
(Please Print in Ink Only)
COMPANY NAME: _________________________________________________________________________________
APPLICANT: ________________________________________________________ BIRTHDATE: _____/_____/_____
(Last Name)
(First Name)
Home Address: _____________________________________________________________________________________
Occupation: ____________________ Monthly Earnings $___________ Daytime Phone # (
S.I.N. # _____/_____/_____
SEX _____ F_____M
) ________________
Height _____________
Weight _____________
Any weight lost or gained in the last 12 months? Yes _______ No _______ and whether Lost _______ or Gained _______
If “Yes” by how much? _______________ (Kgs. or Lbs.) and Why? _________________________________________________________________
1. Within the past twelve months have you consulted a physician or any medical practitioner, been treated for, taken
medication for, or had any known indication of any of the following conditions or disorder of (please state “Yes” or
“No” beside each of the following):
Chest pain or discomfort, high cholesterol or blood pressure ______
Circulatory problems
Disorder of the stomach or intestines
Ulcer, indigestion, gall bladder
Lungs, respiratory system, asthma, shortness of breath
Bronchitis, tuberculosis
Back, neck, knees, hips, muscles, bones, joints
Fibromyalgia or chronic fatigue
Mental or Emotional Disorder
Neuritis, nervous system disorder
Fainting or dizziness, paralysis
Sleep Apnea
Bladder, urinary tract
Prostate, breast or reproductive system
Arthritis, rheumatism
Disorder of the eyes (excluding near or far sightedness), ears (excluding infection that has resolved) or skin (excluding
minor rash or irritation)?
Yes ______ No ______
Been advised that a medical test was abnormal or follow-up is required?
Yes ______ No ______
Do you have any symptoms or complaints for which you have not yet sought treatment?
Yes ______ No ______
Within the past three years have you had any disease or disorder which has limited or interfered with your ability to
perform your daily activities for more than 5 consecutive days?
Yes ______ No ______
Within the past 5 years have you:
a) been confined in a hospital or other institution, been off work, received disability or worker’s compensation
benefits for more than 5 days or disability pension due to an accident or illness?
Yes ______ No ______
b) had an application for insurance declined, postponed, rated or modified in any way?
Yes ______ No ______
Have you ever consulted a physician or any medical practitioner, been treated for or any known indication of:
a) heart or circulatory problems including heart attack, stroke, cancer or tumour, epilepsy, multiple sclerosis, disorder
of the liver, intestines, kidney, blood or immune system?
Yes ______ No ______
b) drug or alcohol abuse, used amphetamines, narcotics, barbiturates, hallucinogens, or marijuana, taken drugs for
other than medicinal purposes, been advised to drink less alcohol, received treatment for drug addiction or
alcoholism, or been charged with driving while impaired?
Yes ______ No ______
c) AIDS, ARC, HIV, enlargement of lymph nodes (glands), chronic diarrhea, unusual skin lesions, or unexplained
infections or other immunological disorder?
Yes ______ No ______
6. List all medications requiring a prescription, that you or your dependents take (exclude birth control pills):
Name of your medication(s)? ____________________________________
Approximate Monthly Cost $__________
Any other medication(s)? _______________________________________
Approximate Monthly Cost $__________
Dependent’s Name? ____________________ Medications? ________________________ Approximate Cost $__________
Dependent’s Name? ____________________ Medications? ________________________ Approximate Cost $__________
Do you or your dependents receive physiotherapy, chiropractic or massage therapy treatments?
Yes ______ No ______
Patient’s name ____________________ Nature of treatment______________ Approximate Monthly Cost $__________
Patient’s name ____________________ Nature of treatment______________ Approximate Monthly Cost $__________
Patient’s name ____________________ Nature of treatment______________ Approximate Monthly Cost $__________
(Please see over and continue)
Declaration of Insurability
Canadian Group Benefit Insurance Programs
1. Do you have any other physical impairment or deformity or health problems or symptoms of illness or disease not listed
in Section I?
Yes ______ No ______
2. Within the past 5 years, have you been hospitalized or under medical observation or had medical, or surgical treatment or
currently receiving medical treatment other than stated in Section I?
Yes ______ No ______
3. Name of address of your personal physician or any medical practitioner(s) or chiropractor consulted in the past 5 years:
4. Date and reason for last consultation(s) for each of the above:
5. Provide details of any medication or treatment prescribed, or advice recommended:
6. Provide details of all yes answers to any questions in Section I or Section II:
Nature of
Date of
Onset / Recovery
Medication and/or
Monthly Cost
Attending Physician or Hospital
(name & address)
SECTION III – Declaration and Authorization to obtain Medical Information
I hereby declare that the above answers and statements are complete and true and that any misstatements or failure to report
information may be used as the basis for rescission of this insurance, as issued to me. I understand that if the insurance
applied for becomes effective, I will be subject to all the terms of the group policy. I agree that any coverage issued in
consequence of this application shall not take effect unless, on the date the insurance would have become effective, I am
actively engaged in my occupation on a full-time basis (full time is defined as 24 hours per week or more). I further agree
that the insurance applied for shall not become effective until the application is approved by the Insurance Company. I
understand the information provided on this document will be treated as confidential and is gathered for the purpose of
underwriting the insurance applied for.
I further understand that additional information including medical testing, may be required as part of the underwriting
process and that this information, including medical test results, will not be shared with my employer.
I hereby authorize any physician, medical practitioner, hospital, clinic or other medical or medically related facility,
insurance company or other organization, institution or person that has any records or knowledge of me or my health to
give Canadian Group Benefit Insurance Programs or its reinsurer(s) any and all information about me with reference to my
health and medical history and any hospitalization, advice, diagnosis, treatment, disease, ailment or condition. A
photocopy of this authorization shall be as valid as the original.
Dated at (City, Prov.)______________________________________________ this _______ day of _______________________________, 20_________
___________________________________ __________________________________
(Applicant’s Signature)
(Signature of Witness)
Form 104/105 DMFM– cgbip (Rev’d. 05/08)
Request and Authorization for the Automatic Cheque Plan
I/We acknowledge that this authorization is provided for the benefit of Advance Benefit Canada Insurance
Solutions Inc. and my financial institution and is provided in consideration of my financial institution agreeing
to process debits against my account in accordance with the rules of the Canadian Payments Association.
Group Policy #_______________ Firm Name _______________________________ Date _____________
I (We) warrant and guarantee t hat all persons whose signatures are required to sign on this account have signed this agreement below. I
(We) hereby authorize Advance Benefit Canada Insurance Solutions Inc. to draw on my account for the following purpose(s): Business
(insurance) and/o r Fund Transfer (registered retirement savings plans).
Signature of Depositor(s) ________________________________
While the Automatic Cheque Plan is in effect, the mode of payment will be monthly and if the required monthly payments
change, a revised statement will be forwarded at least 10 calendar days before the due date to your address of record.
This authorization / agreement may be cancelled at any time upon notice being provided by the payor, either in writing, or
orally with proper authorization to verify the identity of the payor, within 10 business days before the next PAD was to be issued. I (We)
acknowledge that, in order to revoke this authorization, I (we) must provide notice of revocation to Advance Benefit Canada Insurance
Solutions Inc.
I (We) acknowledge that by providing and delivering this authorization to Advance Benefit Canada Insurance Solutions Inc.
constitutes delivery by me (us) to my financial institution. Any delivery of this authorization to you constitutes delivery by me (us).
I (We) acknowledge that the processing member is not required to verify that a PAD has been issued in accordance with
particulars of this PAD Agreement including, but not limited to, the amount. I (We) acknowledge that the processing member is not
required to verify that any purpose of payment for which the PAD was issued has been fulfilled by the payee as a condition to honouring a
PAD issued or caused to be issued by the payee on the account drawn.
Revocation of this authorization does not terminate any contract for goods or services that exists between the payor and the
payee. The Payor’s PAD Agreement applies only to the method of payment and does not otherwise have any bearing on the contract for
goods or services exchanged.
A PAD may be disputed by a payor under the following conditions:
the PAD was not drawn in accordance with the Payor’s PAD Agreement; or
the Payor’s PAD Agreement was revoked; or
pre-notification was not received and such notification was required under the terms of the PAD Agreement.
The payor, in order to be reimbursed, acknowledges that a declaration to the effect that either (i), (ii), or (iii) took place, must
be completed and presented to the branch of the processing member holding the payor’s account up to and including 90
calendar days in the case of a personal PAD or up to and including 10 business days in the case of a business PAD, after the
date on which the PAD in dispute was posted to the payor’s account.
The payor acknowledges that a claim on the basis that the Payor’s PAD Agreement was revoked, or any other reason, is a
matter to be resolved solely between the payee and the payor when disputing any PAD after the above time set out.
Where a disputed PAD is in regards to a Funds Transfer, no recourse is provided through the clearing system. The payor
should seek reimbursement or recourse from the member payee in the event a PAD is erroneously charged to its account.
The account that Advance Benefit Canada Insurance Solutions Inc. is authorized to draw upon is indicated below. A specimen cheque (or
facsimile) if available for this account has been marked “VOID” and attached to this authorization. I (We) undertake to inform Advance
Benefit Canada Insurance Solutions Inc., in writing, of any change in the account information provided in this authorization prior to the
next due date of the PAD.
Attach copy of Void Cheque here.
(This Agreement in accordance with Rule H1 Implemented 15/04/02.)
Disclosure Acknowledgement
The provision of the following information is a requirement of the Financial Institutions Act of British
Columbia. Your licensed agent is assisting you in obtaining the financial product or service indicated by a
check mark in the list below. The name of the company offering that product or service is also shown.
Type of Product or Service
Company Which Offers the Product or Service
Group Life / Disability Insurance
Group EHC / Dental Insurance
ACE INA / Echelon General
Green Shield Canada
Group RRSP / Group Pension
Employee Assistance Program
Wilson Bandwell
(Product must be indicated)
Your licensed agent has a brokerage or single case agreement under the terms of which, the agent is able to
market the products and services of a number of companies. The agent will receive a commission as a
result of this transaction paid by these companies.
The Financial Institutions Act of British Columbia prohibits tied selling. Tied selling is a practice under
which a client who wants to obtain one product or service (for example, a mortgage loan), is forced to also
buy another product (for example, home owners’ insurance), from a specific company, as a condition of
getting the first product (the mortgage loan).
Your agent may use any information received from you to make you aware of other financial products and
services that may be of interest.
I confirm that I have received a copy of this Disclosure Acknowledgement from my agent,
. I consent to the procedures regarding handling of
information described above.
Client Name:
Client Signature:_
Date of Application for the Product or Service indicated above:_
Agent Signature: Jody C. Wright, Ocean Sun Financial 109-4369 Main Street, Whistler BC, V0N 1B4
Your agent is recognized as an independent broker. As such, he is not compelled by the companies
listed above to place your business with them exclusively or any other similar conditions, which could
bias his recommendations to you. The product or services he provides is based upon his assessment
of your stated needs and situation.
E&OE – 04/12