No-Cost Insurance Offer

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1 C a n a d i a n D e n t i s t s I n s u r a n c e P r o g r a m No-Cost Insurance Offer Optional Graduate Package For Dental Students Under Age 40 Medical Underwriting Required To apply for the Optional Graduate Package, you must obtain the Undergraduate Package by your graduation date and return the completed Optional Graduate Package Enrolment and Application Form to CDSPI by December 31 st of your graduation year. For information about the Packages, see the reverse side of this page, which you may detach. Mail: CDSPI, 155 Lesmill Road, Toronto, Ontario, M3B 2T8 Fax: (toll-free) or (416) For assistance, call CDSPI Advisory Services Inc. at or grads@cdspiadvice.com

2 No-Cost* Offer Information Undergraduate Package Double-Up Graduate Package provided automatically** at graduation Optional Graduate Package With Medical Underwriting $200,000 $500,000 Life Insurance $100,000 Waiver of Premium Option 1 Waiver of Premium Option 1 Waiver of Premium Option 1 Future Insurance Guarantee 2 AD&D Insurance $100,000 $200,000 $500,000 LTD Insurance TripleGuard Insurance $1,000/month 90-day elimination period 3 Cost of Living Adjustment 5 $15,000 for student s dental hand instruments $2,000/month 90-day elimination period 3 Cost of Living Adjustment 5 You choose: $15,000 associate coverage OR $50,000 standard coverage $3,500/month 30-day elimination period 3 Cost of Living Adjustment 5 Own Occupation definition 4 Future Insurance Guarantee 2 You choose: $15,000 associate coverage OR $50,000 standard coverage Medical Underwriting for Life and LTD? No No Yes Evidence of insurability required Pre-Existing Condition Exclusion for Life Yes and LTD? Application Deadline Before graduation Before graduation December 31 st of graduation year 50% Reduction on Regular Premiums 6 for Life, LTD, AD&D and TripleGuard Insurance for the 3 calendar years after graduation? Yes Yes Yes * No-cost coverage ends on December 31 st of your graduation year. Coverage is available only to eligible full-time dental students who are enrolled at an accredited Canadian university at the time of application. Coverage in the Undergraduate Package starts on the date on which your properly completed application to enroll is received by CDSPI. The Double-Up Graduate Package automatically starts on your graduation date. The Optional Graduate Package coverage starts on the date of your graduation or the date your application is approved if later. After graduation, you will be sent a separate activation form for TripleGuard Insurance. No medical evidence is required to obtain TripleGuard Insurance. Students who are age 65 or over are not eligible to apply for Life, LTD and AD&D coverage. To apply for the Optional Graduate Package, you must obtain the Undergraduate Package by your graduation date and return the completed Optional Graduate Package Enrolment and Application Form to CDSPI by December 31 st of your graduation year. Coverage is subject to the continued availability of the insurance plans through the Canadian Dentists Insurance Program and this offer. TripleGuard Insurance is provided by Aviva Insurance Company of Canada. Life, AD&D and LTD Insurance are provided by The Manufacturers Life Insurance Company (Manulife Financial). Manulife Financial has the authority to grant or refuse insurance coverage based on health considerations. Precise details, terms, conditions and exclusions are set out in the insurance contracts for these plans. ** Provided that you are not on claim or satisfying an elimination period A pre-existing condition exclusion applies to Life and LTD coverage that is not medically underwritten. Claims arising from an illness or condition for which treatment or advice was or should have been sought during the 12 month period prior to the effective date of coverage are excluded. This exclusion will not apply to any such claim arising after coverage has been in effect for 12 months. 1 With the Waiver of Premium Option, you don t pay premiums if you cannot work because of a total disability lasting six continuous months or more and you are reimbursed for premiums paid in the first six months, provided that a claim for premium waiver is approved by Manulife Financial. 2 The Future Insurance Guarantee (FIG) Option allows you to increase your Life or Long Term Disability (LTD) insurance later on by specific amounts without additional evidence of good health. You must be 50 years old or younger and actively practising dentistry to exercise this option. Please note that LTD FIG Option is subject to financial underwriting and will not be exercisable until you are earning an income. 3 Your elimination period is the length of time you must wait following the onset of total disability before disability benefits first become payable. 4 The Own Occupation Option protects your earning potential. If a continuing total or residual disability prevents you from engaging in your regular occupation (all occupation(s) in which you were engaged immediately prior to becoming disabled), this option allows you to receive LTD income replacement benefits even if you are able to earn income from a new occupation. An any occupation definition of total disability for students applies until you are no longer a dental student. 5 The Cost of Living Adjustment (COLA) Option can help safeguard your purchasing power during disability since it increases your benefit each year (during a period of disability) by the increase in the Consumer Price Index (compounded up to 8 per cent annually). 6 Regular premium rates are subject to change and are not guaranteed.

3 CANADIAN DENTISTS INSURANCE PROGRAM No-Cost* Optional Graduate Package Application Form For Students Under Age 40 (Life, Accidental Death & Dismemberment (AD&D), Long Term Disability (LTD) and TripleGuard Insurance) Provided by Important Notes: You must be age 18 to 39 on the date this Application Form is received by CDSPI and meet other eligibility criteria to receive coverage. If you are age 40 to 64, you must complete a different application. Contact CDSPI for details You must qualify medically to obtain coverage from Manulife Financial. Please answer all questions in Section 3, Declaration of Insurability In order to apply for the Optional Graduate Package, you must be enrolled in the Undergraduate Package. If you are not already enrolled in the Undergraduate Package, CDSPI will automatically enroll you, provided this completed application is received prior to your graduation date If your application is approved, coverage will be effective** at graduation or the date the application is approved, if later, you will pay absolutely no premiums for this coverage up to December 31st of your graduation year. Effective January 1st after your graduation year, you will receive a 50 per cent reduction on regular premiums 6 for the Life, LTD, AD&D and TripleGuard Insurance in the Optional Graduate Package for three calendar years following graduation. Section 1 Applicant Information (To be completed by all applicants.) A. Are you a full-time dental student? 7 B. Are you a Canadian citizen or permanent resident of Canada? 7 7 NOTE: If you answered No to questions A. or B. you are not eligible for coverage. You are eligible for coverage if you are a dental student (or a dentist who was a student and has graduated this calendar year). Student means a full-time dental student enrolled in an accredited Canadian school or faculty of dentistry who is a Canadian citizen or a permanent resident of Canada. C. Name of Person to be Insured (please print): Check one: Mr. Mrs. Miss Ms. Last First Middle or Initial D. University: E. Year of graduation: Year F. Are you enrolled in the qualifying program for foreign-trained dentists? G. Date of birth: H. Country of birth: I. Male Female J. I am a: Smoker Non-Smoker 8 8 The definition of a non-smoker is that you have not used any tobacco products (i.e. cigarettes, pipe tobacco, chewing tobacco, tobacco cessation products, etc.) for 12 months prior to signing this form. K. CDSPI Account Number (if known): L. Current mailing address: Street and Number Suite No. City/Town Province Postal Code Telephone Cellular Telephone Address (please include to expedite the application process) M. Other fixed address: (i.e. an address such as a parent s where you can be contacted if your current address changes) Street and Number Suite No. City/Town Province Postal Code Telephone Please turn over

4 Section 1 Applicant Information (continued) (To be completed by all applicants.) N. Language Preference: English French O. I designate the person named below as my beneficiary to receive any money payable under the Life and AD&D Insurance upon my death. Name of Beneficiary (please print) Your beneficiary designation is revocable* unless you specify otherwise. If you wish to make your beneficiary irrevocable, please contact CDSPI to obtain a form for this purpose. * In Quebec, a spouse designated as beneficiary is irrevocable unless you specify otherwise. I hereby appoint my spouse as a revocable beneficiary: Last First Middle or Initial Beneficiary s Relationship to the Person to be Insured Section 2 Declaration and Authorization (To be read and signed by all applicants/persons to be insured) I apply to The Manufacturers Life Insurance Company (Manulife Financial) for insurance under the group policies issued in connection with the Canadian Dentists Insurance Program. I acknowledge receipt of and confirm my agreement with Manulife Financial s Notice on Privacy and Confidentiality, the Notice on Exchange of Information, Aviva s Privacy Notice and CDSPI s Privacy Notice. I, the undersigned, declare that the statements contained in this application including, if applicable, the statements in Section 3, Declaration of Insurability, are true and complete and, together with any other forms that may be signed by me in connection with this application, form the basis for any policy or certificate issued under the group policies. I understand that any material misrepresentation, including misstatement of smoker status, shall render the Insurance voidable at the instance of the insurer. I understand that if I am required to provide any health information that such information must be accurate as date the Declaration of Insurability is signed. I, the person to be insured, authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medically related facility, insurance company, MIB Group, Inc., the group policy administrator, the insurance plan sponsor, any investigative and security agency, any agent, broker or market intermediary, any government agency or other organization or person that has any records or knowledge of me or my health to provide to Manulife Financial or its reinsurers any such information, to the extent necessary for the purposes of this application and contract and in the event of any subsequent claim. I authorize Manulife Financial to consult its existing files for these purposes. A photocopy or facsimile of this authorization shall be as valid as the original. I declare that I have been made aware of the reasons why the health information is needed and the risks and benefits to the Individual of consenting or refusing to consent. This consent shall take effect on the date of signing of this form and shall expire 7 years after the termination date of any policy or certificate issued as a result of this application. I understand that this consent may be revoked at any time and that, if as a result of such revocation the insurer is unable to obtain proof of claim, this may result in claims not being paid. I understand that for the accidental death and dismemberment and long term disability benefits there are limitations and exclusions that apply. For life insurance, death resulting from suicide within 2 years of the effective date or any reinstatement date is not covered. This application must be received by CDSPI by December 31 st of my graduation year and within 30 days of the signature date below. To apply for the Optional Graduate Package, I must obtain the Undergraduate Package by my graduation date. I understand that my coverage under the Optional Graduate Package does not take effect unless my application is approved by Manulife Financial and such coverage shall not take effect until my graduation date or the date my completed application is approved bv Manulife Financial, whichever is later. Signed at City/Town Province Applicant s Signature Date 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.

5 Section 3 Declaration of Insurability Quebec residents only: When your completed Application Form is returned to CDSPI, Section 3 will be detached and sent to Manulife Financial and no file copy will be retained at CDSPI s offices. However, you also have the choice of detaching Section 3 of this form and submitting it directly to Manulife Financial. If you wish, you may complete the entire Application Form and mail Section 3 only to the following address: ATT: Affinity Markets/CDA Program Underwriting Department, Manulife Financial, P.O. Box 670, Stn. Waterloo, Ontario N2J 4B8. All other sections of the completed application must be mailed to: CDSPI, 155 Lesmill Road, Toronto, Ontario M3B 2T8. Please write your name, date of birth and account number below if you are detaching Section 3 and mailing it directly to Manulife Financial. Name: Date of birth: Account Number: Last First Middle or Initial (if known) University: Year of graduation: Year I) A. Have you ever had Life or Disability Income Insurance declined, postponed, rated, rescinded, cancelled or modified in any way, or have you ever been denied renewal or reinstatement? B. Have you ever made a claim or received benefits, pension or compensation for sickness or accident? C. Do you pilot or navigate (or intend to pilot or navigate) any type of aircraft or do you engage or intend to engage in hazardous activities such as skydiving, hang-gliding, scuba diving, mountain climbing, automobile or motorcycle racing, etc.? D. If you have answered Yes to A, B or C, please provide details: E. name and Address of your Regular Attending Physician: (Where your medical records are located, and if different, the name and address of the medical clinic you last visited.) F. Date and reason last consulted: Date: Reason: G. Diagnosis, treatment given or medication prescribed (if none state None ): H. Results and current status: II) Height M Cm Weight Kg Ft In Lb Any weight change in past year? Indicate amount of change, if any: Loss Reason: Gain Note: If you answer Yes to any of the following questions, you must provide further information in the Medical Details section on the last page. III) Have you during the past 5 years: A. Consulted any physician, chiropractor, psychologist, physiotherapist, psychiatrist or other health care professional or been admitted to any hospital or similar institution? B. Had any symptoms or adverse findings or were you advised to have further examinations, diagnostic tests, hospitalization or surgery not yet done? C. Submitted to ECG, blood tests, X-rays or other diagnostic tests? D. Had any surgical operation, treatment, special diet, illness, ailment, abnormality or injury? E. To the best of your knowledge and belief, had any disease or physical impairment or are you receiving any treatment or are you taking any medication at the present time? IV) Have you ever had or been treated for any disease or disorder of: A. The heart or blood vessels, such as heart murmur, heart palpitations, heart disease, heart attack, angina, chest pain, circulatory problems, phlebitis, stroke, or high blood pressure? B. The chest, lungs, nose, or throat, such as asthma, chronic bronchitis or emphysema? Kg Lb Please turn over

6 Section 3 Declaration of Insurability (continued) C. The digestive system, including stomach, intestines, gall bladder, liver or pancreas, such as ulcer, colitis, bleeding or hepatitis including carrier state? D. The kidneys, bladder, or reproductive organs, such as nephritis, sugar albumin, blood in urine or sexually transmitted disease? E. The nervous system, eyes, or ears, such as dizziness, seizure, paralysis, mental or nervous disorder (including depression or stress) or impairment of sight or hearing? F. The glandular system, or blood, such as diabetes, thyroid, anemia, leukemia or disorder of the breast or skin? G. The immune system, such as persistent lymph gland enlargement, unusual infections or any other immune system abnormality, or had a positive test related to HIV or been diagnosed with AIDS? H. The musculoskeletal system, such as arthritis/rheumatism, sciatica or pain or defect of the back, neck, bones or joints? I. Any other illness, disease, operation, tumour, cancer, injury or congenital defect not listed above? V) A. Are you currently under medical investigation, taking treatment or medication or have you been advised to have or consider treatment or surgery or been referred to another physician? B. Are you immunized against Hepatitis B? C. Do you use alcoholic beverages? If Yes, please record number of glasses in each category. Amount Wine Beer Liquor Daily Weekly Monthly H. Have you ever used sedatives, analgesics, hypnotics, tranquilizers and/or stimulants? I. Have you ever used any form of marijuana, cocaine, narcotics, hallucinogens, heroin, or barbiturates, or sought or received advice or treatment for the use of drugs, prescribed or non-prescribed? J. Have you ever used tobacco or tobacco cessation products? If Yes, date last used: VI) Have you ever lost more than one week at any one time from work, or been disabled, due to accident or illness? VII) Have any of your parents, brothers or sisters had any heart disease, diabetes, cancer, stroke, high blood pressure, kidney disease, Huntington s Chorea or other hereditary disease or genetic disorder? If you answered Yes, please complete the chart below. Family Member Condition (If Cancer, specify type) Age at Onset VIII) Females only: A. Are you currently pregnant? If Yes, give expected due date: Age at Death and Cause B. Have you had any previous complications of pregnancy such as miscarriage, preeclampsia, caesarian section, etc.? D. Have you ever consumed substantially more alcohol than as outlined in C.? E. Have you ever consulted a physician, received treatment or medication or been advised about the excessive use of alcohol? F. Within the past 3 years have you been convicted of or had your driver s licence suspended for any moving violations? G. Do you contemplate any medical or surgical treatment? Continued

7 Section 3 Declaration of Insurability (continued) Quebec residents only: Please write your name, date of birth and account number below if you are detaching Section 3 and mailing it directly to Manulife Financial. Name: Date of birth: Account Number: Last First Middle or Initial (if known) University: Year of graduation: Year Medical Details If any parts of questions III through VIII are answered Yes, you must provide full details below. Include the results of all physical examinations and check-ups. Question Number & Part Date (dd/mm/yy) Name and Address of Physician and Hospital, if any Include (when applicable) all information as to Nature of Illness or Injury, Symptoms, Number of Attacks, Duration, Treatment and Results All persons to be insured: Please note that the insurer may request a medical examination, urinalysis or tests such as a general blood profile, including blood test for HIV/AIDS, which will be made at no expense to the applicant. Results of any positive infectious disease tests will be reported to the appropriate provincial or territorial health department, if required by law /14 Notice on Exchange of Information Must be detached, read and retained by the person to be insured All information requested will be for insurance purposes only and will be treated as confidential. The insurer or its reinsurers may, however, make a brief report on it to the MIB Group, Inc. (MIB). MIB is a non-profit membership organization of life insurance companies which operates an insurance information exchange on behalf of its members. Subject to your authorization, MIB will supply information from its files to another member insurance company to which you have applied for life or health insurance or to which a claim is submitted. On your request, MIB will arrange for disclosure to you of any information it may have in your file. If you question the accuracy of MIB s file, you may contact MIB and seek a correction. The address of the MIB s Information Office is: 330 University Avenue, Toronto, Ontario M5G 1R7. Telephone: (416) canada_disclosure@mib.com

8 Must be detached, read and retained by the person to be insured Manulife Financial s Notice on Privacy and Confidentiality: 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 employees, mandataries, administrators or agents of Manulife Financial 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 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. Aviva s Privacy Notice: Aviva Insurance Company of Canada is committed to protecting your personal information and using or disclosing it only for the purposes for which it is collected. For more information about how Aviva uses and protects your personal information, please refer to Aviva s privacy statement at You may request to review and make corrections to the personal information in the insurer s file by writing to Aviva Canada Inc., Attention: Privacy Officer, 2206 Eglinton Ave. East, Scarborough, Ontario M1L 4S8, or sending an to CAPrivacyOfficer@avivacanada.com. CDSPI s Privacy Notice: 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 policies 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 policies, 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: The Chief Privacy Officer, 155 Lesmill Road, Toronto, Ontario M3B 2T8. For more information about our privacy practices visit