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: firstname.lastname@example.org 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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