For Additional Insurance Under the Future Insurance Guarantee

APPLICATIoN For Additional Insurance Under the Future Insurance Guarantee option For assistance in filling out this application call: CDSPI Advisory Services Inc. 1-877-293-9455 (toll-free) or (416) 296-9455 Ext. 5002, E-mail: insurance@cdspiadvice.com Please complete all pertinent questions to avoid processing delays and return to: CDSPI, 155 Lesmill Road, Toronto, ontario M3B 2T8 Fax: 1-866-337-3389 (toll-free) or (416) 296-8920 CANADIAN DENTISTS’ INSURANCE PRoGRAM A member benefit of the CDA and co-sponsoring provincial dental associations, administered by CDSPI. 09-I01 96099001 Important Note: You must apply within 60 days of the date you attain 25, 30, 35, 40, 45 or 50 years of age, or the date you are married, or the date that a common-law relationship has existed for 24 months, or the date of birth or legal adoption of a child.* * If you are on maternity or parental leave, you may have an extended time period to exercise the FIG Option, Contact CDSPI Advisory Services Inc. for details. Any Future Insurance Guarantee Increase approved will be issued on the same basis as the contract to which the Future Increase Guarantee is attached. INDIVIDUAL INFoRMATIoN Section 1 1. Applicant Information 6. A. Account Number, if known: Mrs. Miss First Name (please print): Check one: Dr. Mr. Ms. Corporation Middle or Initial Last (or name of partnership or corporation) 2. 3. Individuals only: Address: Street and Number City/Town Male Female B. Billing Preference (check one): Same as current Annually Quarterly Pre-authorized Chequing* * Please attach a void cheque. † Monthly Monthly Quarterly Quarterly Annually Annually Suite No. Province Home Telephone Fax Postal Code Please phone us with your credit card information. Automatic VISA/MasterCard† - 4. Business Telephone Mobile Telephone Note: To pay monthly or quarterly, your total Canadian Dentists’ Insurance Program annual premium must be $360 or greater. A 2.23 per cent processing charge applies to monthly and quarterly payments. 7. 8. Language Preference: English French 5. E-mail address (please include to expedite the application process) Social Insurance Number: (For use only on information slips or to satisfy other legal requirements.) Section 2 Person To Be Insured Attainment of age 25, 30, 35, 40, 45 or 50 Common-Law Relationship (specify date commenced) Marriage Note: Please complete even if the person to be insured is the same as the applicant. 1. Name (please print): Check one: Dr. Mr. Mrs. Miss Ms. Last First Middle or Initial Day Month Day Month Day Month Year Year Year 2. 3. 4. Male Female Date of Birth: Birth or Legal Adoption of a child 5. Day Month Year Declaration of eligibility (check one): I am eligible to apply for this coverage without medical evidence of insurability for the following reason (within 60 days): Are you now disabled and on claim or satisfying an elimination period? Yes No If “Yes”, please provide full details. CoVERAGE APPLIED FoR Section 3 Basic Life Insurance 2. Waiver of Premium option: (Available if you are currently insured and carry this option.) This option will be automatically applied to your additional coverage. If you do not want this option applied to your additional coverage, check here: Complete this section only if applying for additional Basic Life coverage under the Future Insurance Guarantee Option. 1. Amount of additional insurance applied for: $ Note: You are eligible to apply for the lesser of the amount of coverage currently in force or $50,000. Total Coverage must not exceed the current plan maximum listed in the Basic Life Insurance plan sheet. Section 4 Beneficiaries by checking the box in the “irrevocable” column below. In Quebec, the designation of a spouse as beneficiary is deemed irrevocable, unless you specify that the designation is revocable by checking the box in the Quebec column below. If you name more than one primary beneficiary, please record the percentage of the death benefit each beneficiary is to receive. If no percentage is recorded, the death benefit will be divided evenly among the surviving eligible primary beneficiaries. You may also name one or more contingent beneficiaries who will receive a death benefit only if: a) no primary beneficiaries are alive when the benefit is payable; or b) a court decides that the primary beneficiaries are not eligible. Note: If sufficient space is not available, please check here and complete a separate signed and dated sheet to be attached to this form. Please follow the format used in the box below, including percentage distribution if naming multiple beneficiaries. Relationship to Proportion Person To Be Insured (%) Check only if making irrevocable (see above) In Quebec, check to make spouse beneficiary revocable Complete this section only if applying for additional Basic Life coverage. 1. Below, list a beneficiary (or beneficiaries) and a contingent beneficiary (if applicable). If a beneficiary is designated as revocable, you will be able to change the beneficiary and make other changes to the coverage at any time without the beneficiary’s consent. If the beneficiary designation is irrevocable, the beneficiary’s written consent will be required in order to change the beneficiary, reduce coverage, cancel the policy, or make any other changes that may affect the value or ownership of the policy. Except for the designation of a spouse as beneficiary in Quebec, a beneficiary designation will be revocable unless you make it irrevocable (for reasons such as satisfying the requirements of a divorce judgment, separation agreement, court order or partnership insurance agreement) Name in Full (Last, First, Middle or Initial) Basic Life Insurance Primary Beneficiary Primary Beneficiary Total 100% Contingent Beneficiary N/A 2. If you named a minor as a beneficiary in the previous question, please provide the name of the trustee appointed to receive any payment due to the minor beneficiary, in the event of the death of the person to be insured. A. Minor Beneficiary Name: B. Trustee Name: C. Relationship of Trustee to Person To Be Insured: Note: If you need more space, please use a separate piece of paper and sign and date it. Section 5 Financial Information Required to process application. Complete only if applying for additional Long Term Disability or Office Overhead Expense Insurance 1. Annual Earned Income: Current Year to Date Actual Last Year End $ $ $ Actual Year Prior to Last Year $ $ $ A. Your gross earned income (from all sources) including salary, fees, commissions and bonuses: B. Less annual total of all your business expenses: C. Net earned income before taxes (A minus B): D. Date of practice fiscal year end: Day Month $ $ $ E. Does your unearned income (investments, interest, pension, etc.) exceed 15% of your total earned income? Yes No If “Yes”, provide the following: Current Year to Date Prior Year Source(s) PROOF OF EXPENSES: If your total* Office Overhead Expense coverage will exceed $3,500/month, please provide a copy of your last income and expense statement. PROOF OF INCOME: If your total* Long Term Disability coverage will exceed $3,500/month, please provide copies of pages 1, 2 and 3 of your last personal tax return. If incorporated, also provide a copy of your last Corporate Financial Statement (all pages). NOTE: If you are a dental specialist in your first two years of practice, no proof of income is required for up to $4,500/month of total* coverage. * Total = All existing and applied for coverage with all companies, including Canadian Dentists’ Insurance Program coverage. Section 6 Insurance Information Complete only if applying for additional Long Term Disability or Office Overhead Expense Insurance 1. A. Do you currently have in force or have you concurrently applied for any sickness or accident coverage (including disability coverage through your employer) or office overhead Expense Coverage, provided by Individual or Group Policies, or Employment Contracts/Partnership Agreements, other than Canadian Dentists’ Insurance Program coverage? Yes No If “Yes”, please complete table below. Amount of Monthly Type of Coverage Benefit ($) Insuring Company or Plan Elimination Period Benefit Period Taxable Benefits (e.g. 5 yrs., to age 65, etc.) Yes No Yes No B. Will any Disability or office overhead insurance be discontinued if this coverage is issued? Yes No If “Yes”, please complete the lines below. Company Amount ($) Type of Coverage NoTE: If the change of coverage described above does not occur, benefits may not be payable under the coverage applied for in this application. Section 7 Long Term Disability (LTD) Insurance * You are eligible to apply for up to 25% of the amount of your FIG option LTD Coverage (rounded to the next higher $100). Total Long Term Disability Insurance coverage (in force and applied for) must not exceed the current Plan maximum specified in the LTD Insurance plan sheet. You must qualify for increased coverage under the Income Ratio Guide at the time you exercise this option. ** Unless you select a longer Elimination Period, the Elimination Period(s) that currently apply to your FIG option LTD Coverage will be applied in the same proportions to your new coverage. Cost of Living Adjustment and Own Occupation Options will be included if you currently have these options. Complete this section only if applying* for LTD coverage under the Future Increase Guarantee benefit on Certificate Number: 1. Amount of additional insurance applied for: 30-Day Elimination Period** $ 60-Day Elimination Period** $ 90-Day Elimination Period** $ 120-Day Elimination Period** $ Total amount of additional insurance applied for:* $ NoTICE oN PRIVACY AND CoNFIDENTIALITY — Must be detached, read and retained by the person to be insured The specific and detailed information requested on the application form is required to process the application. To protect the confidentiality of this information: Manulife Financial will establish a “financial services file” from which this information will be used to process the application, offer and administer services and process claims. Access to this file will be restricted to those Manulife Financial employees, mandataries, administrators or agents who are responsible for the assessment of risk (underwriting), marketing and administration of services and the investigation of claims, and to any other person you authorize or as authorized by law. These people, organizations and service providers may be in jurisdictions outside of Canada, and subject to the laws of those foreign jurisdictions. Your file is secured in our offices. You may request to review the personal information it contains and make corrections by writing to: Privacy officer, Affinity Markets, Manulife Financial, P.o. Box 4213, Stn. A, Toronto, ontario M5W 5M3. Access to information which you provide to CDSPI or CDSPI Advisory Services Inc. or which CDSPI obtains in its capacity as the administrator of the Master Agreement and/or group policy will be restricted to those employees, mandataries, administrators or agents of CDSPI or CDSPI Advisory Services Inc. who are responsible for the marketing and administration of services and the facilitation of claims under the Master Agreement and/or group policy, and to any other person you authorize or as authorized by law. You may request to review and make corrections to the personal information contained in your file at CDSPI or CDSPI Advisory Services Inc. by writing to: Information Access officer, 155 Lesmill Road, Toronto, ontario M3B 2T8. Section 8 Office Overhead Expense (OOE) Insurance 6. Average Monthly Expenses for Professional Practices (your portion) Accounting Services Business Insurance Premiums Association Membership Dues Rent/Mortgage Interest Payments Employee Salaries and Benefits Telephone, Internet Service, Answering Service, Pager Utilities $ $ $ $ $ Interest on Loans, Depreciation/Rental $ Part-time: Complete this section only if applying for additional OOE coverage under the Future Increase Guarantee benefit on Certificate Number: 1. 2. Number of Employees: Full-time: Sole Proprietor Partnership Corporation Associate If a shareholder employee of a professional corporation or a partner, give percentage of ownership: % Total number of Partners, Shareholders or Associates in practice: If expenses shared, your share: 3. 4. (Do not include salary paid to yourself or any member of your profession or any income splitting with a family member) % Note: If expenses are shared, include a copy of expense sharing agreement with the application. $ $ $ 5. Amount of additional insurance applied* for: Elimination Payment option Payment option Benefit Period Period ** #1 (Reducing) #2 (Fixed) 12-month or 14-Day $ $ 24-month 12-month or 30-Day $ $ 24-month Note: The own occupation option will be included if you currently have this option. * You are eligible to apply for up to 25% of the amount of your FIG option ooE Coverage (rounded to the next higher $100). Total office overhead Expense Insurance coverage (in force and applied for) must not exceed the current Plan maximum specified in the ooE Insurance plan sheet or your Total Monthly overhead Expenses as shown in question 6. ** Unless you select a longer Elimination Period, the Elimination Period(s) that currently apply to your FIG option ooE Coverage will be applied in the same proportions to your new coverage. (Electricity, Heat, Laundry, office Maintenance) other customary and reasonable fixed expenses incurred. Please list: Total All Items: Your Share of Total Monthly overhead Expenses (Total coverage in force and applied for may not exceed this amount.) (add all items under item 6) $ Note: Eligible office overhead Expenses apply to expenses incurred in the practice of dentistry only, and not any other type of business. DECLARATIoN AND AUTHoRIzATIoN Section 9 To Be Read and Signed By The Applicant (and Person To Be Insured if Other than the Applicant) I apply to The Manufacturers Life Insurance Company (Manulife Financial) for the insurance indicated above under the group policy(ies) and/or Master Agreement in connection with the Canadian Dentists’ Insurance Program. I/we the undersigned declare that the statements contained in this application are true and complete and together with any other forms or documents signed or provided by me/us in connection with this application form the basis for any policy or Certificate of Insurance issued. I/we understand that any material misrepresentation shall render the insurance voidable at the instance of the insurer. Suicide within two (2) years of the effective date or reinstatement date is a risk not covered. I/we understand that insurance will take effect on the date the properly completed application is approved by Manulife Financial subject to payment of the first premium within 30 days of issuance of a premium invoice, and subject to the person to be insured being actively at work on that date. If the applicant is other than myself I (the person to be insured) consent to the issuance of insurance on my life. I (the applicant) designate the individual(s) named as beneficiary in this application to receive any death benefits payable under the policy or Certificate of Insurance and reserve the right to revoke or alter the interest of any beneficiary, named in this application, subject to any applicable law. I acknowledge receipt of and confirm my agreement with the Notice on Privacy and Confidentiality. A photocopy or facsimile of this authorization shall be as valid as the original. Signature of Person to be Insured (if other than the Applicant) Signature of Applicant Date: Date: Day Month Year Signed at: Signed at: City/Town City/Town Province Province Day Month Year QUEBEC PARTICIPANTS ONLY Les parties ont expressément convenu que la présente entente ainsi que tous annexes ou documents s’y rattachant soient rédigés en anglais. (The parties have expressly requested that this Agreement and any related appendices or documents be drafted in the English language.) NoTE : Ce document est aussi disponible en français. NoTE: Eligibility for coverage or increased coverage is limited to members of CDA and/or co-sponsoring provincial dental associations (in Quebec, eligibility is limited to members of CDA) and employees of participating dental associations or organizations who are Canadian residents. Insurer: The Manufacturers Life Insurance Company (Manulife Financial), Affinity Markets, P.O. Box 4213, Stn. A, Toronto, Ontario M5W 5M3 09-25 07/09