THE EMPIRE LIFE INSURANCE COMPANY APPLICATION FOR GROUP INSURANCE

Transcription

1 Please print; do not use pencil. 1. Policyowner (Full Legal Name): THE EMPIRE LIFE INSURNCE COMPNY PPLICTION FOR GROUP INSURNCE Head Office Use Policy Number 2. ddress: Street/Suite City Province Postal Code Telephone Fax Internet ddress ( ) ( ) Policy dministrator: (Give Name and title of person to whom correspondence and billings should be directed): 3. Nature of Business (Goods or services provided): 4. Ownership (check one): Sole Proprietorship Partnership Corporation Name(s) of Owner(s), if Sole Proprietorship or Partnership: 5. Billing Type: Head Office Self dministered Third Party dministered (must be an approved Empire Life TP) Employees to be listed in: Certificate Number Order or lpha (by Surname) Order 6. Policy Effective Date: 12:01 a.m. on - Day / Month / Year 7. Renewal Date: Day / Month 8. Subsidiary Companies to be Included (Print full legal name(s). If more than 2, complete, initial and attach Subsidiary Company ppendix ). #1 Name Street/Suite City Province Postal Code Telephone Fax ( ) ( ) Policy dministrator (Give Name and Title of Person to whom correspondence and billings should be directed). Business relationship to Policyowner: Common Ownership (Yes) Number of Employees on Payroll: Nature of Business: Is a separate Billing required (for mailing to the Subsidiary ddress)? Yes No If Yes, Division Number: If No, is a subtotalling by subsidiary company within Division desired? If Yes, see 9. Billing Subtotalling. pplication for Group Insurance 1

2 8. Subsidiary Companies to be Included (Continued). #2 Name Street/Suite City Province Postal Code Telephone Fax ( ) ( ) Policy dministrator (Give Name and Title of Person to whom correspondence and billings should be directed). Business relationship to Policyowner: Common Ownership (Yes) Number of Employees on Payroll: Nature of Business: Is a separate Billing required (for mailing to the Subsidiary ddress)? Yes No If Yes, Division Number: If No, is a subtotalling by subsidiary company within Division desired? If Yes, see 9. Billing Subtotalling. 9. Billing Subtotalling Is a subtotalling (by department or by subsidiary company) of the billing required? Yes No If Yes, indicate desired Department Code (alpha/numeric, 5 character maximum): Code: Code: Code: Description: Description: Description: Note that all enrolment cards must indicate their respective Department Code if billing subtotals are desired. 10.Present Coverage Will the insurance applied for replace similar insurance? Yes No. If Yes, complete this section. Benefit Name of Insurer & Policy Number Date of Termination Life.D. & D. Weekly Indemnity Long Term Disability Extended Health Dental ttach a list of employees who have wholly or partly satisfied their deductibles, if applicable. 11. Eligible Employees Employees who are active, full time, who reside in Canada, employed on a permanent basis in Canada, and working a minimum of 20 hours per week. or Employees who are active, full time, who reside in Canada, employed on a permanent basis in Canada, and working a minimum of hours per week, subject to a minimum of 20 hours per week. Coverage also being extended to: Retirees Early Retirees (age to 65) Part-time Employees ( hours per week). Total Number of Employees to be insured as of the Policy Effective Date: Total Number of Employees on payroll as of the Policy Effective Date: If different, please explain: pplication for Group Insurance 2

3 12. Definition of Salary Base salary only, or inclusive of commissions If commissions are to be included, salary to be based on: the previous calendar year T-4, or the average of the previous 2 year s T-4s. 13. Division and Class Structure Division # Class Class Description 14.Waiting Period (length of time employees must be employed by the Policyowner to be eligible for coverage) Benefit (note all if same for all Benefits) a) Number (e.g. 3) b) Timeframe (e.g. months) c) Of continuous employment (Y or N) d) If not continuous employment, describe e) pplies to present and future employees? f) pplies to future employees only? Note: check only one of e or f for each Class. 15. Premium Contributions (Indicate the percentage of the cost to be paid by the Policyowner for each Benefit) a) Employee Life b) Employee D&D c) Dependant Life d) *Weekly Indemnity e) *Long Term Disability f) Extended Health g) Dental * Disability benefits (Weekly Indemnity or Long Term Disability) are taxable if the Employer pays any portion of the premium for the benefit. pplication for Group Insurance 3

4 16. Participation Participation under this Plan is Mandatory* Non-mandatory** * If participation is Mandatory, 100% of all eligible employees who are actively at work must be insured for all benefits for which they are eligible. If the plan is 100% employer paid, it is a Mandatory plan. ** If participation is Non-mandatory, an eligible employee is allowed to refuse all coverage under the Policy, subject to the minimum participation requirements of the Policy. n employee refusing coverage under the Policy must refuse all coverage. Refusal of some, but not all coverage, is not permitted. If the Policy includes Extended Health and/or Dental Benefits, an eligible employee may waive coverage for these benefits if insured for similar coverage under their spouse s plan. Such waivers will not affect the participation level. SCHEDULE OF BENEFITS 17. Employee Life Benefit Yes No Employee.D.& D. Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) Life Schedule b) Life Maximum mount c) D&D Schedule d) D&D Maximum mount e) Reduction Schedule f) Termination ge No Evidence Limit $. ny Employee Life Insurance and/or.d. & D. in excess of the No Evidence Limit will be granted only subject to evidence of insurability satisfactory to the Company for plan enrolees under age 65. ge 65 and over, any Employee Life Insurance and/or.d. & D. in excess of one half of the No Evidence Limit will be granted only subject to evidence of insurability satisfactory to the Company..D. & D. includes Loss of Use of Extremities..D. & D. to include Waiver of Premium? Yes No 18. Employee Optional Life Benefit Yes No Employee Optional.D.& D. Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) Optional Life Schedule - Units of b) Optional Life Maximum mount c) Optional D&D Schedule - Units of d) Optional D&D Max mount e) Reduction Schedule f) Termination ge (65 or 70) Employee Optional.D. & D. to include coverage for Loss of Use of Extremities? Yes No Evidence of insurability is required for all amounts of Employee Optional Insurance benefits. pplication for Group Insurance 4

5 19. Dependant Life Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) Spouse mount b) Child mount c) Include Dep.. D. & D. (Y or N)? d) Termination ge* *Termination ge is based on the age of the employee. Dependant Life Benefit includes Spousal Conversion privilege. Coverage for dependant children commences upon the attainment of the age of 24 hours. Dependant Life to include Waiver of Premium? Yes No 20. Spousal Optional Life Benefit Yes No Spousal Optional.D.& D. Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) Optional Life Schedule - Units of b) Optional Life Maximum mount c) Optional D&D Schedule - Units of d) Optional D&D Maximum mount e) Reduction Schedule f) Termination ge (65 or 70)* Spousal Optional.D. & D. to include coverage for Loss of Use of Extremities? Yes No * The termination age for Spousal Optional Insurance benefits is the earlier of the termination of the Insured Employee s participation in the Policy, or the spouse s attainment of age 65 or 70, as indicated above. Evidence of insurability is required for all amounts of Spousal Optional Insurance benefits. 21. Weekly Indemnity Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) Percentage of Weekly Salary b) Maximum Weekly Benefit c) Injury Elimination Period (days) d) Sickness Elimination Period (days) e) Incl. 1st Day Hospitalization (Y or N) f) Maximum Benefit Period (weeks) g) Termination ge No Evidence Limit $ Taxable Benefit? Yes No re these benefits to be registered under the Employment Insurance (E.I.) Premium Reduction Plan or any Government Sponsored Plan? Yes No Occupational (24 hour) coverage? Yes No (If No, the benefit is not eligible for E.I. premium reduction.) Carve Out Plan? (No benefit is payable during the 15 week Employment Insurance disability benefit period.) Yes No pplication for Group Insurance 5

6 22. Long Term Disability Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) Percentage of Monthly Salary?, or Graded Scale? Please indicate scale below. b) Maximum Monthly Benefit c) Injury Elimination Period (days) d) Sickness Elimination Period (days) e) Maximum Benefit Period f) Own Occupation Period (indicate period) or ny Occupation (indicate ny ) g) CPP/QPP Integration (Primary, Secondary or None)? h) Termination ge Graded Scale (if applicable) % of the first $. % of the next $. % of the next $, and % of the excess. No Evidence Limit $ Taxable Benefit? Yes No Survivor Benefit? Yes No If Yes, number of months: 3 months 6 months Cost of Living djustment (COL) Clause? Yes No If Yes, the percentage is %. The all source maximum benefit is 85% of pre-disability Take Home Pay when benefits are Non-Taxable, or 85% of pre-disability Monthly Earnings when benefits are Taxable. 23. Extended Health Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) nnual EHB Single Deductible (indicate amount) b) nnual EHB Family Deductible (indicate amount) DRUG BENEFIT n Yes Yes n No No c) Include Infertility Treatments (Y or N) d) Include Smoking Cessation Treatments (Y or N) e) Include Erectile Dysfunction Treatments (Y or N) Pay Direct Drug Card: n Yes Yes n No No f) Indicate Type: Prescription (Rx), Prescription Generic (RxG), Prescribed (RxB), or Prescribed Generic (RxBG) g) Deductible mount per Prescription (indicate amount) h) Coinsurance (indicate percentage) i) Deductible Equal to Dispensing Fee (Y or N) j) nnual Single/Family Deductible on Drug Card (indicate amounts) k) Dispensing Fee Maximum (indicate amount) Note: in the absence of a maximum, a reasonable & customary provincial maximum will be administered. l) Preferred Provider rrangement? (attach specifications) m) Drug Benefit, Benefit Period Maximum (unlimited, or indicate amount) Empire Reimbursement: n Yes Yes n No No n) nnual EHB Deductibles pplicable? (Y or N) o) Coinsurance (indicate percentage) pplication for Group Insurance 6

7 23. Extended Health Benefit (continued) HOSPITLIZTION BENEFIT Yes Yes No No p) Semi-Private Hospitalization (Y or N) q) Private Hospitalization (Y or N) r) nnual EHB Deductibles pplicable? (Y or N) s) Hospitalization Coinsurance (indicate percentage) MJOR MEDICL BENEFIT Yes Yes No No t) Major Medical Coinsurance u) Major Medical subject to the EHB deductible? (Y or N) v) Vision Care? Indicate maximum amount (every 2 years) w) Vision Care benefit period for children under age 18 (1 or 2 years) x) Vision Coinsurance equal to Major Med Coinsurance? (If No, indicate %) y) Vision Care to be subject to EHB Deductible? (Y or N) z) Convalescent Hospital; $20/day (Indicate maximum # of days: 120 or 180) aa) Convalescent Hospital Coinsurance equal to Major Med Coinsurance? (If No, indicate %) bb) Convalescent Hosp. subject to the EHB Deductible? (Y or N) cc) Private Duty Nursing (PDN) Maximum (indicate amount) dd) PDN Maximum amount - over a period of 1, 2, or 3 years? ee) Hearing id Maximum (indicate amount) ff) Hearing id Maximum over a period of 4 or 5 years? PRMEDICL SERVICES (Maximum is per Benefit Period) gg) Per Practitioner Benefit Period Max (indicate amount not to exceed $1,000) Doctor s referral required on Masseur only hh) Reduce Paramedical max by the Coinsurance. (Y or N) ii) Include first dollar Paramedical coverage (Y or N) (See Representative for availability) OUT OF PROVINCE OF RESIDENCE BENEFIT jj) Out of Province of Residence Referral (Y or N) kk) Out of Province of Residence Emergency (Y or N) ll) Out of Province of Residence MEDeMERG Travel ssistance (Y or N) GENERL INFORMTION mm) Termination ge (indicate age) nn) Overall Lifetime EHB Max per Person Insured (indicate unlimited, or indicate amount) oo) Survivor Benefit (If Yes, indicate 1 or 2 years) pp) Benefit Period - indicate Cal for Calendar Year, or Pol for Policy Year qq) re claim forms to be authorized by the Policyowner? (Y or N) rr) re claim payments to be sent directly to the employees? (Y or N) Cost Plus ddendum is included for EHB, if EHB is insured under the Policy. The Termination ge for Insured Dependant Children is the attainment of age 22; 26 if full-time student at an accredited educational institute. Notes: pplication for Group Insurance 7

8 24. Dental Benefit Yes No Note ll in the Class row if coverage applies to all classes, and coverage details are the same for all classes. a) nnual Dental Single Deductible (indicate amount) b) nnual Dental Family Deductible (indicate amount) c) Recall Frequency; indicate 5 Month, 9 Month, or 12 Month d) Fee Guide Year; Fixed (indicate year), or Current Year (indicate C ) e) Fee Guide based on Province of employee residence (Y or N) f) If not based on Province of residence, specify Province g) Level 1: Basic Restorative - Coinsurance percentage h) Level 2: Periodontics & Endodontics - Coinsurance percentage i) Level 3: Major Restorative - Coinsurance percentage j) Level 4: Orthodontics - Coinsurance percentage k) nnual Maximum: Level 1 & 2 Combined l) nnual Maximum: Level 3 m) nnual Maximum: Level 1, 2 & 3 Combined n) Lifetime Maximum: Level 4 o) re dults to be included in Orthodontic coverage (Y or N) p) Termination ge (indicate age) q) Survivor Benefit (if Yes, indicate 1 or 2 years) r) Benefit Period: Indicate Cal for Calendar Yr., Pol for Policy Yr. s) re claim forms to be authorized by the Policyowner? (Y or N) t) re claim payments to be sent directly to the employee? (Y or N) Cost Plus ddendum is included for Dental, if Dental is insured under the Policy. The Termination ge for Insured Dependant Children is the attainment of age 22; 26 if full-time student at an accredited educational institute. The Termination ge for Dependant s Orthodontic Coverage is the attainment of age 20. Notes: pplication for Group Insurance 8

9 25. Unit Premium Rates The actual premium rates at inception of the Plan will be determined in accordance with the employee data as at the Effective Date of the Policy. Note ll in the Class row if Rates are the same for all Classes. a) Employee Life (per $1,000 of insurance) b) Employee.D. & D. (per $1,000 of insurance) c) Dependant Life d) Dependant.D. & D. e) Weekly Indemnity (per $10 of insurance) f) Long Term Disability (per $100 of insurance) g) Extended Health Benefit: Single h) Extended Health Benefit: Family i) Dental Benefit: Single j) Dental Benefit: Family Optional Life (per $1,000 of insurance) ge Band Smoker Male Smoker Female Non-Smoker Male Non-Smoker Female Under 30 $0.12 $0.06 $0.07 $ $0.12 $0.08 $0.07 $ $0.17 $0.11 $0.09 $ $0.27 $0.19 $0.15 $ $0.47 $0.30 $0.24 $ $0.79 $0.47 $0.41 $ $1.32 $0.69 $0.70 $ $2.00 $1.02 $1.07 $ $2.89 $1.53 $1.57 $0.92 Optional.D. & D. Rate (per $1,000 of insurance): Premium Rates for Spousal Optional Life (and.d. & D.) equal Employee Optional Life Premium Rates, if Spousal Optional Life (and.d. & D.) insured under the Policy. 26. Special Considerations pplication for Group Insurance 9

10 27. Corrections / mendments / Clarifications pplication for Group Insurance 10

11 28. General Information a) If there have been any lay-offs in the past five years, indicate the class and number of eligible employees who were so affected. Is a lay-off provision required? Yes No If Yes, number of months (not to exceed 6). Layoff provision will be provided for all insured benefits except Weekly Indemnity and Long Term Disability. b) re all employees covered by the provincial Workplace Safety and Insurance Board (WSIB) / Workers Compensation Board (WCB)? Yes No If No, indicate those employees not covered. c) re benefits Union negotiated? Yes No If Yes, include a copy of the collective agreement. re all Classes Union negotiated? Yes No If No, which Classes are union Negotiated? d) re any proposed insureds employed on a contract or consultant basis, or as directors or sub-contractors of the Policyowner? Yes No If Yes, indicate those employees. If Yes, are such employees working exclusively for the Policyowner? Yes No If Yes, are such employees ongoing employees? Yes No If No, are there known termination dates regarding their term of employment? e) Do any employees work a reduced work week or participate in a workshare programme? Yes No If Yes, indicate those employees. f) If the Policyowner is primarily based in a Province other than Quebec: i) Is there a physical business location (e.g. branch, warehouse, sales office) in the Province of Quebec? Yes No ii) Do you have employees who hold their principle residence in Quebec, but work in a province other than Quebec? Yes No If Yes to ii), do you wish to provide such employees with Drug coverage which complies with Quebec Universal Drug Legislation? Yes No pplication for Group Insurance 11

12 29. Disabled Employees 1) re there any employees absent from work due to sickness or injury? Yes No If Yes, please provide details below. 2) re there any individuals who are not insured with the present carrier and who are currently receiving disability benefits from a prior carrier? Yes No If Yes, please provide details below. 3) re there any individuals who are absent from work due to: i) Maternity/Parental Leave? Yes No Please provide details under 4) below. ii) Layoff? Yes No Please provide details under 4) below. i) Leave of bsence? Yes No Please provide details under 4) below. Employee Name a) Date of Disability b) Date of Birth c) Class and/or Occupation d) Nature of Disability e) Prognosis f) Present coverage? g) Is this a WSIB Claim? h) pplied for LTD with present carrier? i) pproved for LTD with present carrier? j) pplied for Life Waiver of Premium? k) pproved for Life Waiver of Premium? l) If approved, provide copy of approval for waiver letter or a copy of the present carrier s billing If any question f) through k) has been answered No, an explanation must be provided and submitted with this pplication for Group Insurance. 4) Employees on Maternity/Lay-Off/Leave of bsence Employee Name Class/Occupation Reason for bsence Date of Leave Expected Date of Return pplication for Group Insurance 12

13 30. Pre-authorized Payment Plan How does the plan work? You continue to receive your monthly statement as usual, detailing all the changes. The total amount due is deducted automatically from your bank account each month. The automatic withdrawal is processed on the 10th day of each month (or the next business day) for the premium due for the billing period for that month. When does the plan start? You will be notified on the billing statement when your account has been switched to the Pre-uthorized Payment Plan. Please continue to pay your monthly statement in the usual manner until you receive this notification. If you should make any changes in your banking arrangements or need to notify us of any changes in your banking procedures, please call Terms & Conditions This Pre-uthorized Payment Plan is for the convenience of our client. There are no charges to enroll in the plan. The client certifies that the information provided in the authorization is correct and that the client will notify Empire Life in the event of any changes. The client certifies that his/her bank account is in good standing with sufficient funds to cover pre-authorized payments as they come due. ll pre-authorized payments will be drawn on Canadian financial institutions only and will be withdrawn in Canadian Funds. Cancellation This agreement can be terminated, upon written notification, at any time, by either the client or Empire Life. Upon termination, any amount due shall be paid directly to Empire Life. Cancellation of pre-authorization payment does not constitute cancellation of service by Empire Life and the client shall be liable for any past, present or future amounts owing. UTHORIZTION GREEMENT Yes, I/we hereby authorize Empire Life to withdraw the amount due on my/our billing statement from my/our financial institution on the 10 th day of each month (or the next business day). Please attach a void cheque. 31. Ontario Retail Sales Tax (RST) - Election Form To be used: a) If you are/would be licensed under the Ontario Retail Sales Tax ct in order to submit RST on employee premium due on a Group Insurance Policy only. (Section 3.2(3)) b) If you are a licensed vendor under the Ontario Retail Sales Tax ct, however you want the Empire Life Insurance Company to submit the RST on employee premiums. (Section 3.1(3)) DECLRTION Yes, the pplicant for this Group Insurance Policy elects to remit the full Ontario Retail Sales Tax payable on both the employee and employer premiums to The Empire Life Insurance Company in accordance with Regulation 1013 of the Revised Regulations of Ontario, 1990 made under the Retail Sales Tax ct, Section 3.1(3) and 3.2(3), as applicable. pplication for Group Insurance 13

14 32. Declaration and Signatures (Signatures must be originals) The pplicant hereby declares that, to the best of the pplicant s knowledge, the statements and answers contained above are full, complete and true as of the date hereof and agrees that: (1) such statements and answers shall constitute the pplication for and form part of the Contract, and (2) the insurance will become effective in accordance with and subject to the terms and conditions of the Policy to be issued to the pplicant but in no case shall it become effective until this pplication has been approved by The Empire Life Insurance Company. In the case of errors or omissions discovered by The Empire Life Insurance Company in this pplication, the said Company is hereby authorized to amend this pplication by noting the change in the section entitled Corrections/mendments/Clarifications and acceptance by the pplicant of the Policy accompanied by a copy of this pplication so amended, shall constitute ratification of such Corrections/mendments/Clarifications. n initial Premium Deposit Cheque in the sum of $ is included with this pplication. The amount of the Premium Deposit must be no less than 80% of the value of the first month s premium. Negotiation of the cheque will not, of itself, constitute approval of the pplication. I request that any contract issued as a result of this pplication be issued in the English language. Dated at this day of, pplicant - Full Company legal name - please print Signature of uthorized Company Official Title - please print Name of uthorized Company Official - print name in full Signature of Witness Title - please print Name of Witness - print name in full pplication for Group Insurance 14

15 33. Producer s Information Producer s Commitment: To the best of my/our knowledge and belief all statements in this pplication are true and complete. I/we have read and understand the form. Signature of Producer Signature of Second Producer - print name in full Name of Producer - print name in full Name of Second Producer - print name in full Producer s Name Use this column if there are two Producers Company Name ddress - Street/Suite City, Province Postal Code Telephone Fax Internet ddress Resource Centre Group Office Empire Life Producer Code Percentage of Case pplication for Group Insurance 15

16 G-0-ENG-05/01 pplication for Group Insurance 16

17 WHY EMPIRE FINNCIL GROUP? n Empire to Be Proud Of For more than 75 years we ve worked together to provide total income security and investment opportunities to Canadians. Empire has grown considerably since its founding in 1923 and today we are among the top 15 life insurance companies in Canada. We re proud of our heritage and our reputation for offering quality, innovative products with a dedication to personalized service. How We Measure Up.M. Best Company: (Excellent) as of September 27, 2000.M. Best Co. has affirmed our (Excellent) financial strength rating. The rating reflects our strong capitalization and stable earnings from our core individual life insurance business. One of the Top 15 Life Insurance Companies in Canada Empire ranked 11th in the National Post Business 500: Top 25 Life Insurers, June 2000, based on consolidated general fund assets, Canadian and worldwide, excluding segregrated funds. MCSSR: 244% Empire has maintained a strong MCSSR (Minimum Continuing Capital and Surplus Requirement) ratio of 244% at the end of 1999, which is well in excess of the minimum regulatory requirement of 120%. Our Employee Benefits Division We have provided Canadian Business with outstanding products and services for over 30 years. Since our establishment, we have continued to grow as a significant, competitive force within the group insurance industry by capitalizing on our unique strengths: People: Our network of highly qualified, experiences sales and service oriented support staff provides customized, personal service to our clients. Performance: We pride ourselves on our reputation of superior implementation of new benefits and we commit to service in writing. Empire has printed Service Standards for issue, claims payment and administration and a proven track record for meeting these standards. Technology & Innovation: Our modern systems architecture allows us to be most efficient and adaptive to the business environment of today and of the future. Our website can be located at Focus: Our focus is to serve Canadian small business. Location: We currently insure more than 3000 group accounts from Vancouver to Halifax. Regional offices can be found in most major centres across Canada, with corporate Head Offices in Kingston and Montreal. EMPIRE FINNCIL GROUP TM TM Trademark of The Empire Life Insurance Company G-0-ENG pplication for Group Insurance 17