SPECIAL ENROLMENT FORM FOR POST-RESIDENCY INSURANCE PROGRAM _LIFE

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SPECIAL ENROLMENT FORM FOR POST-RESIDENCY INSURANCE PROGRAM _LIFE Powered By Docstoc
					                                                                                                                         ONTARIO MEDICAL ASSOCIATION
                                                                                                                         Special Offer to Medical Students
                                                                                                                         NO Evidence of Health Required

                                      APPLICATION FOR STUDENT DISABILITY INCOME – POLICY 50140
                               REQUEST FOR OMA GROUP TERM LIFE PLUS 75 INSURANCE PLAN – POLICY G-29500
   Disability Income is underwritten by Sun Life Assurance Company of Canada and Life Insurance is underwritten by New York Life Insurance Company, NY, NY 10010

SECTION 1: YOUR PERSONAL INFORMATION
                                                                                                                                                                                 (b)         Male
1.(a) Name
                                                                                                                                                                                             Female
                                      Last Name                                     First Name                                       Middle Initial

2. Date of Birth                                                  Place of Birth:                                                                           Citizenship:
                       Month            Day           Year
3. Address:                                                        Send correspondence to:               Residence             Alternate

   Residence                                                                                     Alternate




                                                          Postal Code                                                                                             Postal Code

                    Tel# (        )                                                                           Tel# (       )                                Fax# (               )

  Email
  Address

  If you plan to move within the next 6 months,              Residence:                                                        Alternate:

  please indicate your new address/phone
  information:

                                                             Tel # (         )                                                 Tel # (                )
                      Effective Date of Change:

                                                                  Month                    Day               Year                        Month                       Day                     Year

4. Have you ever used: marijuana, tobacco or nicotine in any form, or any tobacco cessation or nicotine replacement product?                                Yes              No

   If “Yes”, please indicate date last used:                      Date Last Used
                                                                                                             Month               Year


SECTION 2: ABOUT YOUR MEDICAL STUDIES
5. (a) Provide the date you started                                                                    (b) Provide the date you
       Medical School                                                                                      expect to graduate
                                                  Month            Day              Year                                                              Month                  Day              Year
   (c) If your graduation date has
      been extended, please explain
      reason reason:
  (d) Provide the name of your                                                                       (e) What is your current year
       Medical School or University:                                                                     of Medical School:                                1st         2nd           3rd          4th
  (f) Please check the provincial medical association in which you are a member for insurance eligibility:
         OMA           DNS           NBMS             NLMA            MSPEI
(If you are not a member, please contact your provincial medical association/society to arrange for membership. In the meantime please continue with this application)

SECTION 3: $100,000 STUDENT LIFE COVERAGE
6. (a) Are you applying for Student Life Coverage?                Yes            No
I am applying for the first $100,000* of coverage under Policy G-29500-0. I understand I am not eligible to apply if I am already insured under the Policy. I also understand
that the Waiver of Premium benefit is excluded from the coverage I am applying for. (* You may not be insured under this plan if you are already insured as a spouse under
this policy or under policy G-3900-0 issued by New York Life.)

   If “Yes”, please complete 6(b):                                        If “No” go to Section 4
  (b) Beneficiary Designation -- I hereby make the following beneficiary designation for my life insurance:
                                              Name                                                      Relationship                                             Date of Birth
                                                                                                                                                          (please provide only if a minor)


                                                                                                                                                      Month                Day             Year
SECTION 4: DISABILITY COVERAGE
7. Are you applying for Disability Income          Yes       No
     If “Yes” go to question 8                                If “No” - go to Declaration and Authorization

8.       Please indicate the coverage you wish to apply for (check  either Plan A or Plan B):

                                   PLAN A                                                                 PLAN B

                                 YEARS 1 & 2                                                           YEARS 1 & 2

                              i) Disability Income                                                   i) Disability Income
                               - $1,000 per month                                                     - $1,500 per month
                               - COLA and GIB                                                         - COLA and GIB
                               - HIV/Hepatitis B&C Benefit                                            - HIV/Hepatitis B&C Benefit

                              ii) Student Overhead Expense                                          ii) Student Overhead Expense
                                  - $ 500 per month                                                    - $ 500 per month
                                  - GIB                                                                - GIB

                                 YEARS 3 & 4                                                           YEARS 3 & 4

                                 Disability Income increases                                           Disability Income increases
                                 to $1,500 and Student                                                 to $2,500 and Student
                                 Overhead Expense is unchanged                                         Overhead Expense is unchanged
                                                                                                                                               Yes
9. (a) Do you have in force or have you concurrently applied for any disability income coverage (other than OMA insurance)                                 If “Yes”, provide details bellow
                                                                                                                                               No

         Amount of                                                Indicate if individual                              Elimination Period       Benefit Period
                               Insuring Company or Plan                                          Date of Issue                                                     Taxable Benefits
         Monthly Benefit                                          or group/association                                (e.g. 90 days)           (e.g. to age 65)
                                                                                                                                                                      Yes
                                                                                                                                                                      No
                                                                                                                                         Yes
     (b) If “Yes” to 9(a), will any disability insurance be discontinued if this application is approved?                                        If “Yes”, please indicate below:
                                                                                                                                         No

         Company                                                            Amount           $                       Policy Number

DECLARATION AND AUTHORIZATION
I declare that my answers in this Application are true and complete and I understand that concealment, misrepresentation or false declaration concerning this Application will cause this
insurance to be void. As a member of the Ontario Medical Association, Newfoundland and Labrador Medical Association, New Brunswick Medical Society, The Medical Society of
Prince Edward Island, or Doctors Nova Scotia, I understand and agree that this application is void unless I am enrolled full-time in Medical School in Ontario, Nova Scotia or
Newfoundland and Labrador, and reside in Canada (excluding Quebec) on the date of this application.
I understand that this request for coverage will be accepted up to 60 days prior to the commencement of medical school, and that insurance will become effective
on the later of the date this request for coverage is received by OMA Insurance or the date I begin medical school, provided I am alive and any premium contribution required
has been received by OMA Insurance within 45 days of the date I am billed. I also understand that any experience refunds apportioned to group policy G-29500 will be paid
to the OMA.
I understand that the answers to Section 1, question 4, may result in reduced contributions once I am required to make such contributions and that: (a) if these answers are not true
and complete this could invalidate coverage, and (b) if I cease to be eligible for the non-smoker rates because I use one or more of the listed products, I will be required to pay the
higher smoker rates.
I authorize New York Life Insurance Company and Sun Life Assurance Company of Canada and their agents, subsidiaries, service providers and reinsurer to use, obtain and
exchange relevant information about me for underwriting, administration and adjudicating claims and to use and exchange information with OMA Insurance for the purpose of
administration under this insurance coverage. New York Life, Sun Life and their subsidiaries, agents, reinsurer and OMA Insurance may also release information to those I
subsequently authorize in writing.
A photocopy or electronic version of this authorization shall be as valid as the original.

Signed at                                                                                                 This                      of
                                     City                                   Province                                    Day                    Month                     Year
Name of Applicant                                                                                    Signature of
(Please Print)                                                                                       Applicant

AS-334 (01/2010)
Note: Regarding Policy G-29500 for purposes of the Insurance Companies Act (Canada), this document was issued in the course of New York Life Insurance Company’s
insurance business in Canada.

                           Return completed application to: OMA Insurance, PO Box 365 STN Waterloo, Waterloo, ON N2J 4A4

                                                                                                                                                       Source Code: 05-915

				
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posted:7/28/2010
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