insurance application
Transcription
insurance application
You must save the file on your hard drive prior to filling the form electronically. 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