The Manufacturers Life Insurance Company - Help Manufacturers Life Insurance Company (Manulife)

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  • Advisor ID:

    Advisor Name:

    Advisor E-mail:AIR MILES Collector #: 8

    Flexcare Application *All applicants must complete Parts A, B, C, D and E*All applicants must complete and sign theApplicants Authorization and Declaration

    Applicants First Health CardLast Name__________________________________ Name ________________ Initial ____ Number

    Apt. Street NumberNumber______ and Name ___________________________________________ Home Telephone ( ) _______________________________

    City or PostalTown _________________________________________ Province___________ Code __________ Occupation __________________________

    Co-Applicants FirstLast Name__________________________________ Name ________________ Co-Applicants Occupation __________________________________

    Applicants Office Telephone ( ) ____________________________ Co-Applicants Office Telephone ( ) __________________________

    Applicants Email ______________________________________________ Co-Applicants Email____________________________________________

    If additional information is required, how may we contact you? q Home q Office q Email Best time to call ________________ AM PM

    Are you now covered by or did you recently have employer group health insurance coverage? q Yes q No

    If Yes, please indicate:

    Group Plan Number ______________________________________________ ID Number________________________________________________

    Insurance Company ______________________________________________ Date Benefits Ended ________________________________________

    Group Plan Number ______________________________________________ ID Number________________________________________________

    Insurance Company ______________________________________________ Date Benefits Ended ________________________________________

    Part A General Information

    (DD/MM/YYYY)

    Beneficiary designation for payment of Accidental Death and Dismemberment benefit in the case of death (if no beneficiary designation is made, benefits will be payable to the estate):

    Applicants Beneficiary

    Name ____________________________________________________

    Relationship to Applicant ______________________________________

    % of Benefit ______________________________________________

    Name of Trustee ______________________________________________

    Relationship to Beneficiary ____________________________________

    If you designate a beneficiary who is a minor when benefits become payable, benefits will be paid into court or to the Public Trustee, unless a Trustee is appointed. By appointing a trustee below, you agree that if the beneficiary is a minor on the date that benefits are paid, the benefits will be paid to the trustee to hold in trust for the child until the child comes of age.

    Co-Applicants Beneficiary

    Name ______________________________________________________

    Relationship to Co-Applicant____________________________________

    % of Benefit ______________________________________________

    Name of Trustee ______________________________________________

    Relationship to Beneficiary ____________________________________

    (DD/MM/YYYY)

    Page 1 of 6

    I hereby designate the individual(s) named as beneficiary(ies) on this application to receive any death benefit payable with respect to the coverage applied for. If no beneficiary is designated, benefits will be payable to the Estate.

    The Manufacturers Life Insurance Company

    WSF

  • Part B Plan Choice

    Remember: Your Plan Choice applies to all family members.

    I/We apply for: CORE PLANS ADD-ONS STAND-ALONES Available only with a Core plan Available without a Core plan

    q DrugPlusTM Basic q Travel +8 days* q Hospital Basic

    q DrugPlus Enhanced q Travel +21 days* q Hospital Enhanced

    q DentalPlusTM Basic* q Accidental Death & Dismemberment Enhanced * q Catastrophic Coverage ($4,500 deductible)

    q DentalPlus Enhanced* q Hospital Basic q Catastrophic Coverage ($10,200 deductible)

    q ComboPlusTM Starter* q Hospital Enhanced

    q ComboPlus Basic q Catastrophic Coverage ($4,500 deductible)

    q ComboPlus Enhanced q Catastrophic Coverage ($10,200 deductible)

    q Vision Enhanced * (Not available with ComboPlus Starter)

    * These plans do not require completion of the Medical Questionnaire of this application.

    APPLICANT

    CO-APPLICANT

    DEPENDANT

    DEPENDANT

    DEPENDANT

    DEPENDANT

    LAST FIRSTNAME NAME

    HEALTH CARD NO. CODE SEX BIRTH DATEDD MM YYYY

    AGE SMOKER?NO. OF

    CIGARETTESDAILY

    HEIGHTinch / cm

    WEIGHTlbs / kg

    WEIGHT CHANGEIN LAST YEARGAIN LOSS

    REASON FORWEIGHT CHANGE

    00

    01

    02

    02

    02

    02

    Flexcare Application*All applicants must complete Parts A, B, C, D and E

    *All applicants must complete and sign the Applicants Authorization and Declaration

    If you require more space to complete any part of this application, please attach a separate sheet, signed and dated.

    Page 2 of 6

    Part D Payment Options

    Initial Payment: I/We hereby authorize Manulife to debit the initial two (2) months premium, $ , using my/our:

    Option #1 q Pre-Authorized Debit (PAD)

    Option #2 q Credit Card Account

    IMPORTANT: Initial Payment will be taken on the day approved (not the effective date). Future payments will be taken on the first of each month.

    Subsequent Payments will be made by:

    Option #1 q Pre-Authorized Debit (PAD)

    PAD Billing Frequency: q Monthly q Semi-Annually (2% discount) q Annually (4% discount)

    Important: For verification purposes, we require a sample cheque marked VOID. Please complete Part E.

    Option #2 q Credit Card Account

    Credit Card Billing Frequency: q Monthly q Semi-Annually q Annually

    Please note: Billing frequency discounts are not available for credit card payment options. Please complete Part E.

    Option #3 q Direct Billing (Excludes initial 2 months payment)

    Direct Billing Frequency: q Semi-Annually (2% discount) q Annually (4% discount)

    Part C Individuals to be Covered

  • Credit Card Option Payment Information & Payment Authorization

    I/We hereby authorize Manulife to make a withdrawal from my/our account on or about the first business day of each month in which insurance premiums are due.This Authorization may be terminated by either Manulife or by me/us through written notice. Manulife may terminate coverage or change the method of payment toanother qualifying method should a withdrawal be refused for any reason and the financial institution shall in no way be held liable should such an event occur. A $25.00 fee will be charged for all NSF (Non-Sufficient Funds) transactions.

    Credit Card: q Visa q MasterCard q American Express

    Card Number __________________________________________________________________ Expiry Date ______________________________

    Name of Cardholder ________________________________________ Signature of Cardholder___________________________________________

    Second Signature if Joint Account ____________________________________________________ Dated___________________________________

    Pre-Authorized Debit (PAD) Payment Information & Payment Authorization

    Please use the following banking information:

    q From the cheque used to make the first payment

    ORq As follows: (only complete the table below if you do not have a void cheque)

    Transit Number ________________ Institution Number ______________ Bank Account Number___________________________________________

    Financial Institution __________________________________________ Address _____________________________________________________

    Joint Accounts: Is this a joint account requiring only one signature? q Yes q No

    If more than one signature is required on withdrawals issued against the account, both account holders must sign this authorization.

    Non-Chequing Accounts: Since approval from my/our financial institution is required for pre-authorized payments from accounts with no chequing privileges, I/we havemade prior arrangements to allow for pre-authorized payments from my/our account. Enclosed is a withdrawal slip that has been stamped by my/our financial institutionallowing withdrawals to be made from my/our non-chequing account.

    Signature of Account Holder _______________________________________________

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