insurance application

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INSURANCE
APPLICATION
Association des jeunes médecins du Québec
Policy 53072 - Period from October 1, 2016 to September 30, 2017
2197 Sherbrooke Street East, suite 200, Montréal (Québec) H2K 1C8
CP 47115 CSP Sheppard, Québec (Québec) G1S 4X1
Montreal: 514 871-1181 | Quebec: 418 681-7785 | Toll-Free: 1 877 371-1181
Fax | Montreal: 514 871-4943 | Toll-Free: 1 877 871-4943
[email protected] | www.medicassurance.ca
INFORMATION ABOUT YOU
Last name
Woman
Man
Date of birth (day / month / year)
First name
English
French
Place of birth (province / country)
E-mail address
Smoker
Non-smoker Non-smoker means that you have not used any tobacco products or tobacco cessation products within the last 12 consecutives months
Address
Residence
Office
City
Province
Postal code
Telephone (residence)
Telephone (office)
Fax
INFORMATION ABOUT YOUR SPOUSE
Required only if you apply for Couple or Family coverage
Name (last name, first name)
Common law spouse:
Yes
Woman
Man
Date of birth (day / month / year)
No Occupation: ____________________
Date of cohabitation (day / month / year): ________________________
Smoker
Non-smoker Non-smoker means that you have not used any tobacco products or tobacco cessation products within the last 12 consecutives months.
INFORMATION ABOUT YOUR CHILDREN
Required only if you apply for Single Parent or Family coverage
Name of the child (last name, first name)
Date of birth (day / month / year)
Sex
Student
Female
Male
Yes
No
Female
Male
Yes
No
Female
Male
Yes
No
Female
Male
Yes
No
To ensure the confidentiality of the personal information held on you, MédicAssurance inc. will set up an insurance file in which be entered the information provided on your insurance application,
as well as any claim information.
Only those employees or representatives responsible for underwriting, investigating and processing claims or any other person authorized by yourself will have access to this file. Your file will be
kept in our offices. You are entitled to consult the personal information contained in this file and to have it rectified, if necessary, by sending a written request to one of the following addresses:
- 2197 Sherbrooke Street East, suite 200, Montréal (Québec) H2K 1C8 - CP 47115 CSP Sheppard, Québec (Québec) G1S 4X1
IMPORTANT: Your insurance coverage will be effective on the 1st of the following month upon receipt of your application duly completed unless you specify otherwise hereunder. The coverage cannot
be effective other than the 1st of the month.
I wish my coverage be effective on the 1st of the month of ___________________________. Your initials ____________
You must save the file on your hard drive prior to filling the form electronically.
MEDICAL FORM
Association des jeunes médecins du Québec
Policy 53072
2197 Sherbrooke Street East, suite 200, Montréal (Québec) H2K 1C8
CP 47115 CSP Sheppard, Québec (Québec) G1S 4X1
Montreal: 514 871-1181 | Quebec: 418 681-7785 | Toll-Free: 1 877 371-1181
Fax | Montreal: 514 871-4943 | Toll-Free: 1 877 871-4943
[email protected] | www.medicassurance.ca
Required only if you apply for enhanced coverage (A, B, C)
INFORMATION ABOUT YOU
Last name
1I
First name
During the last six (6) months, have you or your dependents received a diagnosis or treatment and/or
been prescribed medication for one of the following conditions:
YES
NO
Cerebrovascular disorder
Artery or vein disorder, including aneurysms
Neurological disorder
Infectious disease, hepatitis C, HIV, AIDS
Respiratory or pulmonary disorder (excluding cancer)
Gastro-intestinal disorder or other internal disorders (excluding cancer)
Rheumatoid arthritis, ankylosing arthritis or any other form of arthritis
Cancer
Diabetes
Crohn’s disease
PLEASE PROVIDE DETAILS FOR ALL QUESTIONS TO WHICH YOUR ANSWER IS “YES” .
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
2 I At this time are you taking or do you have a prescription for one or more specialty or exceptional medications?
YES
NO
PLEASE PROVIDE DETAILS IF YOU HAVE ANSWERED THIS QUESTION “YES”.
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
DECLARATION AND AUTHORIZATION
I, the undersigned, declare that my answers in this application are true and complete and I understand that concealment, misrepresentation and false declaration concerning this application will cause the insurance to be void. A photocopy version of this declaration is as valid as the original, and shall remain in effect for the duration of my insurance coverage.
Signature of the applicant
(electronic signatures are not accepted)
Date of the signature (day / month / year)
Direct card
Monthly premium 9% tax excluded
BASIC OPTION
Generic drugs mandatory with $1 046 deductible / adult - reimbursement: 100%
AGE
COVERAGE
Single
Couple
Single parent
Family
Less than 25
$60.11
$89.59
$120.20
$143.39
25 - 29
$61.07
$91.02
$122.12
$145.68
30 - 34
$65.13
$98.65
$130.25
$153.65
35 - 39
$109.65
$200.26
$219.30
$239.36
40 - 44
$122.28
$242.54
$244.56
$315.25
45 - 49
$131.99
$264.15
$244.56
$341.11
50 - 54
$166.40
$325.00
$260.56
$360.18
OPTION A
Generic drugs mandatory with deductible $857 / $857 - reimbursement: 100%, Extended Healh Benefit – Travel
AGE
COVERAGE
Single
Couple
Single parent
Family
Less than 25
$7.79
$19.71
$31.19
$38.35
25 - 29
$7.79
$19.71
$31.19
$38.35
30 - 34
$8.62
$20.76
$31.29
$38.35
35 - 39
$47.46
$114.99
$73.91
$123.38
40 - 44
$69.05
$138.20
$109.65
$179.63
45 - 49
$75.21
$150.51
$123.12
$194.36
50 - 54
$109.59
$207.51
$136.52
$233.72
OPTION B
Generic drugs mandatory - reimbursement: 100%, Extended Health Care - reimbursement: 75%, deductible $857 / $857 applicable to drugs and extended health care
excluding hospital expenses, expenses incurred outside the province, Extended Healh Benefit – Travel
AGE
COVERAGE
Single
Couple
Single parent
Family
Less than 25
$61.28
$92.41
$107.47
$165.41
25 - 29
$63.60
$103.99
$109.79
$173.51
30 - 34
$86.78
$173.51
$132.96
$208.29
35 - 39
$96.77
$193.52
$157.18
$241.97
40 - 44
$136.24
$272.44
$238.34
$374.75
45 - 49
$151.19
$302.32
$264.47
$415.83
50 - 54
$195.67
$391.30
$293.40
$489.20
OPTION C
Generic drugs mandatory - reimbursement: 75%, if generic drugs - reimbursement: 100%, Extended Health Care - reimbursement: 75%, deductible $150 / $300
applicable to drugs and extended health care excluding hospital expenses, expenses incurred outside the province, Extended Healh Benefit – Travel
AGE
COVERAGE
Single
Couple
Single parent
Family
Less than 25
$63.60
$127.17
$138.75
$173.51
25 - 29
$69.40
$138.75
$161.93
$179.31
30 - 34
$104.16
$202.49
$185.11
$260.43
35 - 39
$104.16
$204.71
$197.55
$300.05
40 - 44
$171.33
$342.62
$313.93
$471.22
45 - 49
$190.11
$380.20
$332.63
$522.89
50 - 54
$270.55
$541.09
$405.73
$676.43
DENTAL INSURANCE
(Available with options B and C)
No deductible - reimbursement: 80%
COVERAGE
Single
Couple
Single parent
Family
$50.38
$100.78
$100.78
$136.42
Rév. 10 / 2016
You must save the file on your hard drive prior to filling the form electronically.
PAYMENT
AUTHORIZATION
Association des jeunes médecins du Québec
Policy 53072 - Period from October 1, 2016 to September 30, 2017
2197 Sherbrooke Street East, suite 200, Montréal (Québec) H2K 1C8
CP 47115 CSP Sheppard, Québec (Québec) G1S 4X1
Montreal: 514 871-1181 | Quebec: 418 681-7785 | Toll-Free: 1 877 371-1181
Fax | Montreal: 514 871-4943 | Toll-Free: 1 877 871-4943
[email protected] | www.medicassurance.ca
PREMIUM PAYMENT METHOD
I wish to use the following means of payment:
Preauthorized bank payments: administration fee of $2 per transaction, except for an annual payment.
Please complete the “Preauthorized Bank Payment Authorization” section.
Annual
Semi-annual
Quarterly
Bimonthly
Monthly
Credit card: administration fee of 2% of the premium.
Please complete the “Credit Card Payment Authorization” section.
Quarterly
Bimonthly
Monthly
Annual
Semi-annual
Annual cheque: Please calculate your premiums pro-rated (amount of the monthly premium x number of months covered) to reflect the annual renewal date of
the policy. The period covered is indicated below. Your cheque should be made payable to MédicAssurance Inc.
PRE-AUTHORIZED PAYMENT
I hereby authorize MédicAssurance Inc. to withdraw from my account, the details of which appear on the attached specimen cheque, the sum of $ ____________ on the
1st day of each month and to change the amount to be debited from my account in case of a change in the premiums for which notice has been given 30 days’ prior to the
date on which the change takes effect.
SIGNATURE OF ACCOUNT HOLDER(S): _____________________________________ _____________________________________
(electronic signatures are not accepted)
DATE (day / month / year): ____________________
TYPE OF SERVICE:
Personal
Business
I may revoke my authorization at any time, subject to providing notice of 30 days. To obtain a sample cancellation form, or for more information on my right to cancel a PAD
(Pre-Authorized Debit) Agreement, I may contact my financial institution or visit www.cdnpay.ca.
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.cdnpay.ca.
ATTACH A SPECIMEN CHEQUE MARKED “VOID”
Copy is accepted
CREDIT CARD PAYMENT AUTHORIZATION
I hereby authorize MédicAssurance inc. (plan administrator) to charge my credit card for the amount due according to my insurance certificate and to adjust the amount
charged to my credit card should the premiums change if a 30 days notice in writing has been given prior to the adjustment. This authorization can be cancelled at any time
with 30 days written notice.
Visa
MasterCard
American Express
CARD NUMBER: ______________________________________________________ EXPIRATION DATE (day / month / year): _________________
CARDHOLDER NAME (as indicated on the card): _______________________________________________________________________________
SIGNATURE: ______________________________________________________ DATE (day / month / year): ___________________________
(electronic signatures are not accepted)
THE CONSEQUENCES OF NON-PAYMENT
You are solely responsible for the consequences of a non-payment and any obligations that it may give rise to under the terms and conditions of the policy contract.
You are in default of payment when a pre-authorized payment is not honoured because of non-sufficient funds, closed account or other similar reasons.
If your financial institution does not honour a debit because of non-sufficient funds, MédicAssurance Inc. will debit that amount again with the next monthly debit along with a fee of $45
after return not honoured. MédicAssurance Inc. may also terminate this agreement and the annual premium would then be due for al policies covered by this Agreement.
A notice of “Stop Payment” initiated by you without prior agreement with MédicAssurance Inc. for the payment of the premium, will result in the cancellation of all policies covered
by this Agreement.
DOCUMENT TO BE COMPLETED AND RETURNED, ACCOMPANIED
BY THE APPLICATION DULY COMPLETED.
Rev. 09/2016
ABONNEMENT / SUBSCRIPTION
RENOUVELLEMENT / RENEWAL
1er février 2016 au 31 janvier 2017 / February 1st, 2016 to January 31, 2017
Nom/Name :
Sexe : M
Prénom/First Name :
F
Date de naissance/Date of birth :
Adresse/Address :
Ville/City :
Code postal/Postal Code :
Tél. (rés.)/Tel. (Res.) :
Tél. (hôp.)/Tel. (Hosp.) :
Courriel/E-Mail : ______________________________________No pratique/Licence No. :
Êtes-vous assuré(e) auprès de MédicAssurance? Do you have insurance with MédicAssurance?
Si oui / If yes :
* Si non / If no :
Assurance médicament collective/Group insurance for medicare
Assurance invalidité /Disability insurance
Nous autorisez-vous à transmettre votre nom à MédicAssurance?
Do you authorize us to give your name to MédicAssurance?
oui/yes
oui
yes
non*/no*
non
no
NOUVEAU MEMBRE / NEW MEMBER (20 ans ou moins de pratique / 20 years practice or less)
Médecin de famille / Family Doctor
80 $ + tx = 91,98 $
Autre médecin spécialiste / Other Specialist : _____________________
80 $ + tx = 91,98 $
MEMBRE ACTIF / ACTIVE MEMBER (20 ans ou moins de pratique / 20 years of practice or less)
Médecin de famille / Family Doctor
160 $ + tx = 183,96 $
Autre médecin spécialiste / Other Specialist : _____________________
160 $ + tx = 183,96 $
MEMBRE ASSOCIÉ / ASSOCIATE MEMBER (21 ans ou plus de pratique / 21 years of practice or more)
Médecin de famille / Family Doctor
210 $ + tx = 241,45 $
Autre médecin spécialiste / Other Specialist : _____________________
210 $ + tx = 241,45 $
CONTRIBUTION VOLONTAIRE / VOLUNTARY CONTRIBUTION
______________$
TPS : 867562936RT0001 / TVQ : 1021875666TQ0001
Veuillez faire parvenir votre chèque à l’ordre de l’AJMQ / Please send your cheque payable to AJMQ
Paiement par carte de crédit, vous pouvez retourner par fax au : (514) 282-4292
Payment by Credit Card, you can send by fax to: (514) 282-4292
VISA
Master Card
No : ______________________________________
exp.
/
Nom de la personne sur la carte de crédit/Name on the Credit Card :
Signature
Nom & prénom en lettres moulée
1370, Notre-Dame Ouest, Montréal (Québec) H3C 1K8 / Tél (514) 879-9203 • Télécopieur (514) 282-4292 • www.ajmq.qc.ca
12-2015