CGA Travel Brochure - PDF by czl10931

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									                    Application
I hereby apply for Travel Pac coverage as offered to
members of CGA-Canada and certify I am covered
                                                                                Annual Worldwide                                                                 Insurance Program
                                                                                                                                                              Programme d’Assurance
                                                                                                                                                                                                        Annual Worldwide
under a provincial hospital/medical plan.                                        Travel Protection                                         CGA Canada provides unique insurance benefits for members.   Travel Protection
Member
Name                                                                                                                                       Benefit plans include:
                                                                                                                                           • a comprehensive employee benefits program for
Date of Birth
                                                                                                                                             practitioners                                               Out-of-Province Emergency
Address                                                                                                                                    • corporate employee benefits program for any company
                                                                                                                                             owned or managed or who employ a CGA professional            Medical Travel Insurance
                                          Province                               How Can I Apply?                                          • Emergency Out-of-Province/Country Medical Travel Plan
Postal Code                               Telephone #                            Apply for Travel Pac by filling out the attached form     • Business Overhead Insurance.
                                                                                 and returning it to Johnstone’s Benefits along with
Name of Beneficiary
                                                                                 your cheque, payable to Johnstone’s Benefits, for the
Relationship to Insured                                                          applicable premium. Contact Johnstone’s Benefits if
                                                                                 payment is to be made by VISA or MasterCard.
Spouse (If Family plan selected)                                                                                                                           Marketed through
Name                                                                             How Long Am I Covered For?
                                                                                 Travel Pac provides annual coverage for an unlimited                    Fabrizio (Fab) Biagini
Date of Birth
Beneficiary for spouse and children (if applicable) is the member.
                                                                                 number of trips, up to 60 days per trip, throughout
                                                                                 the year.
Children        (If Family plan selected)
Name                                      Date of Birth                          Help is Only A Phone Call Away ...SOS
Name                                      Date of Birth                          Along with your Travel Pac policy, you will receive a
                                                                                 wallet-sized SOS card ... your international phone
Name                                      Date of Birth
                                                                                 number, putting you in touch with people who will
Note: Provide information on additional children, if any, on a separate list.
                                                                                 assist with your immediate needs. One call to SOS
Signature of Member                                                              will help with hospital arrangements, transfers and                     3095 Woodbine Drive
                                                                                 translation if necessary.                                           North Vancouver BC V7R 2S3
Date

                                                                                 How Do I Make A Claim?                                                 Phone: (604) 980-6227
Insurance is effective on the date your application is
received by Johnstone’s Benefits.                                                Simply contact Johnstone’s Benefits for claim forms.                     Fax (604) 983-2935
                                                                                 Remember                                                             Toll free: 1 (800) 432-9707
 Annual Premium                (Check one only)
 Ages 18 to 64                               Ontario*             Quebec*
                                                                                 This plan is available only to CGAs, CGA Students                   Web Site: www.jbenefits.com
                                                                                 and their families. This brochure is only intended as
 Member Only           ■ $ 88.00             ■ $ 95.04            ■ $ 95.92                                                                           E-mail: fab@jbenefits.com
                                                                                 a summary of the benefits provided. Benefits are
 Family Plan           ■ $176.00             ■ $190.08            ■ $191.84
                                                                                 subject to all conditions, limitations, exclusions, co-
 Ages 65 to 74                                                                   insurance, deductibles or maximums in the master
 Member Only           ■ $228.00             ■ $246.24            ■ $248.52      policy issued to CGA-Canada.
 Family Plan           ■ $456.00             ■ $492.48            ■ $497.04

 Ages 75 to 79
 Member Only           ■ $438.00             ■ $473.04            ■ $477.42
                                                                                 This brochure is meant to provide a summary of                        Insurance Provided by
                                                                                 benefits. The terms and conditions contained in the
 Family Plan           ■ $876.00             ■ $946.08            ■ $954.84
                                                                                 master contract held by the policyholder will prevail
*Includes applicable taxes
                                                                                 in the event of any discrepancy.

Annual premiums can be paid by VISA or MasterCard in
addition to paying by cheque.
MEDICAL COSTS CAN BE ASTONISHING                                                                                   Travel Pac – Accidental Death,
                                                                                                                   Dismemberment and Total Paralysis
                                                                                                                   Your coverage also includes the following
Don't be caught without coverage. Take advantage of this package                                                   amounts (principal sum) of accident




                                                                                                                                                                              Please complete the application form on the reverse and return it with your payment to:
                                                                                                                   insurance:
offered exclusively to CGAs, CGA Students and their families.                                                          CGA member                    $100,000
Provincial Governments are reducing the amount of          • Artificial limbs, eyes or other prosthetic                Family (if applicable):
coverage for Out-of-Province medical emergencies.            appliances                                                Spouse                        $ 50,000
The cost of medical care in the United States and          • Emergency air transportation back to Canada               Each Child                    $ 15,000
other countries is rising dramatically. As a result, you     (max. $2,000)                                             If No Spouse                  $ 25,000
are personally responsible for any excess billings over                                                            Note: The principal sum is doubled in case of paralysis.
                                                           • Other services and supplies including casts,
and above what is eligible under your government
                                                             splints, braces, crutches, oxygen, plasma, blood
insurance plan.                                                                                                    Additional Benefits
                                                             transfusions and rental of therapeutic equipment
Out-of-province medical coverage is a must.                                                                        • Repatriation – to a maximum of $10,000
                                                           • Return of vehicle (max. $500)
                                                                                                                   • Rehabilitation – to a maximum of $10,000
               CGA Annual Travel Insurance                 • Rental of television/telephone while an inpatient
                                                             in a hospital (max. $200)                             • Education – to a maximum of $5,000
               Protection                                                                                          • Day Care – to a maximum of $5,000




                                                                                                                                                                                                                                                                        North Vancouver BC V7R 2S3
              The last thing you need when you             • Hotel Convalescence (after hospital stay of not
                                                             less than 7 days) to a maximum of 20 consecutive      • Home/Vehicle Alteration – to a maximum of
              travel is to be saddled with unforeseen                                                                $10,000
                                                             days at $50/day (max. $1,000)




                                                                                                                                                                                                                                                                            3095 Woodbine Drive
                                                                                                                                                                                                                                                                            Johnstone’s Benefits
              expenses as a result of an accident or
                                                                                                                   • Seat Belt – pays an additional 10% of the principal
              sickness. That’s why CGA Canada has
                                                           Maximum Limit                                             sum if injured while wearing a seat belt
arranged for extensive, low-cost Travel Protection.
                                                           $1,000,000 per person per policy year.                  • Occupational Training – to a maximum of $10,000
The coverage provides 24-hour accident and medical
insurance protection whenever you or your                                                                          • Family Transportation and Accommodation – up to
immediate family leave your Province of Residence.         Eligibility                                               75% of expenses to a maximum of $5,000
                                                           • As the primary iinsured, you must be 18 years old
Travel Pac - Medical                                         but under 80.                                         The Policy Does Not Cover
                       One annual policy for any                                                                   a) Intentionally self-inflicted injuries
                                                                         • Spouse means the legal spouse of
                       number of trips per year, to a                      the insured person residing in          b) War, act of war, perpetration of acts of terrorism,
                       maximum trip length of 60 days,                     Canada or someone of the opposite          participation in a riot, insurrection or civil
                       covers expenses incurred for:                       sex with whom the member has               commotion
                       • Hospital and medical expenses                     continuously co-habited for a           c) Pregnancy, childbirth or complications within two
                         including hospital room and                       minimum of one year.                       months of due date
                         board                                                                                     d) Travel for the purpose of obtaining medical
                                                                         • Child or children means any natural
•   Physician’s fees and surgical procedures                                                                          treatment
                                                                           child, step-child or legally adopted
•   Prescription drugs                                                     child of the insured person living in   e) Conditions for which treatment was received
•   Out-patient services                                                   Canada, under 25 years of age and          within 6 months prior to date of departure,
•   Local licensed ambulance service (max. $5,000)                         must be a full-time student.               except chronic conditions stabilized by regular
                                                                                                                      use of prescribed medication
•   Services of a private duty nurse
•   Emergency Accidental Dental Services
                                                           Please Note:                                            f) Participation in any professional athletics
    (max. $2,000)                                          • Sickness or accident must occur while you are         g) Participation in acrobatic or stunt flying,
•   Services of a licensed physiotherapist when              insured under the policy.                                mountaineering, hang gliding, scuba diving, racing
    ordered by a doctor                                                                                               or speed contests
                                                           • The policy will respond after other coverages are
•   Services of licensed chiropractors, podiatrists,         exhausted including government and group              h) Elective treatment
    naturopaths, chiropodists, osteopaths, speech            insurance plans.                                      i) An individual who is not covered under a
    therapists, licensed psychologists and masseurs                                                                   government hospital/medical insurance plan
    to a maximum of $300 per year (masseur requires
    doctor’s recommendation)                                                                                       Note: All expenses must be incurred on a non-elective
                                                                                                                         emergency basis.

								
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