Request for Approval - Person with Disabilities Toll Exemption on the Port Mann Bridge

Transcription

1 Request for Approval - Person with Disabilities Toll Exemption on the Port Mann Bridge The personal information collected on this form is collected under the authority of the Transportation Investment Act (SBC 2002, c.65, Section 25) and is subject to the provisions of the Freedom of Information and Protection of Privacy Act (RSBC 1996, c.165, Section 26 (a) and (c)). The personal information collected will be used to verify and assess eligibility for toll exemption status on the Port Mann Bridge for persons with disabilities. In processing your application, your personal information may be shared with the Ministry of Social Development or Service Canada in order to confirm your eligibility as a person with disabilities. Exempt vehicles are subject to regular audit and this application may be reviewed by government auditors. For more information regarding the collection and use of your personal information pelase contact the TReO Privacy Officer at TREO (8736) or TREO (8736). The Privacy Officer is located at Woolridge Street, Coquitlam, BC, V3K 0B8. Please complete the application in full. Applications that are incomplete and/or missing required documentation will not be processed. Part 1 Customer Information (please print clearly) Application (MM/DD/YYYY) TReO Account # (if known): Licence Plate Number (for exempt vehicle): First Name: Last Name: Full name of person with disability (Name must match ICBC registration papers) Mailing Address: City: Province: Postal Code: Phone: Preferred Contact Method: Mail Page 1 of 4

2 Required Documentation You must submit a copy of all the required documents to support your proof of disability. Please note that only applications with all required documentation will be processed. Incomplete or missing documentation will not be approved for exemption. Please check each box for the documents you have included. All Applicants: A copy of current ICBC insurance and registration papers for the exempt vehicle. (The name on the ICBC insurance document must match the name on this application) Person with Disabilities Exemption Categories There are 3 categories that qualify for Exemption on the Port Mann Bridge. Please select only one category (check boxes A, B or C) and provide the associated documentation outlined below to confirm your proof of permanent disability. A. Persons with Disabilities Designation - Ministry of Housing and Social Development 1. A copy of Ministry of Social Development disability assistance cheque stub or a copy of a letter from the Ministry of Social Development confirming designation under the BC Employment and Assistance with Persons with Disabilities Act as a person with disabilities, dated within the last 12 months. 2. AND a Form HR0095 A Release of Personal Information form issued by the Ministry of Social Development, dated within the last 12 months. B. Persons with Disabilities Designation - Canada Pension Plan Disability A copy of official documentation verifying that you have been approved for AND are currently receiving the Canada Pension Plan Disability benefit, dated within the last 12 months. (Contact Service Canada at to request this documentation. Cheque stubs are not acceptable.) C. Persons with Disabilities Designation - Physician Certification A physician signed and stamped copy of Part 2 (of this application) dated within 12 months of the application. (Applications not completed, signed or stamped by a physician will be considered incomplete.) Page 2 of 4

3 Vehicle Eligibility Requirements You must meet the requirements below to qualify for a toll exemption on the Port Mann Bridge. Please check all applicable boxes. Your exempt status is only applied to the vehicle designated in Part 1 of this application. I am a BC resident I own or lease the vehicle applying for the exemption As the registered owner of the vehicle, you are considered the primary contact of your TReO Exempt account. If you would like to add another person as an authorized contact on your account, please call TReO at TREO (8736) or TREO (8736) and a customer service representative will set this up for you. This would enable a secondary contact to ask questions or make changes to your account on your behalf. Renewal - Important Information Every 5 years you must submit a new application and the required documents to support your proof of disability to be exempt from paying tolls on the Port Mann Bridge. Please note that only applications with all required documentation will be processed. Applications with incomplete or missing documentation will not be approved for renewal. This exemption is valid for five years. At any time during that period TReO may contact you to validate or reconfirm your exempt status, which may include resubmitting documentation. How long does my Exempt Status stay active? Once approved, your Exempt Status will be active for 5 years and is only applied to the designated vehicle. If your Toll Exemption expires before you submit a new application with updated documentation, you are liable for any charges on your TReO account. Applications can take 2-3 weeks to process, so please submit your renewal at least 1 month prior to the expiration date to ensure no extra charges are incurred. What happens if I purchase a new vehicle or get a new licence plate? If you cross the Port Mann Bridge with a vehicle that has not been approved for exemption, you will be responsible for any toll charges and additional fees that are incurred. You must contact TReO to update your account with this new information. Applicant s Signature: I have read and agree with the preceding requirements and conditions. Approval Process Your Exempt Status will be confirmed when you receive a letter along with a TReO exempt decal. Once received, your decal will need to be installed on the vehicle that you have identified in Part 1 of this application. It is important to note that your application can take 2-3 weeks to process, so until approved, you are liable for any toll charges or fees that you incur on the Port Mann Bridge. Please visit to review the full terms and conditions. Page 3 of 4

4 Requirements and Conditions I understand and agree to the following conditions. I am responsible for paying tolls and fees incurred by crossing the Port Mann Bridge until: 1. My 5 Year toll exempt status has been approved and registered in the TReO System. Once approved, I understand the Tolling Exempt Status is valid for only the vehicle identified in Part 1 of this document. 2. My TReO exempt decal is installed in my vehicle. 3. I have contacted TReO to inform them about any licence plate or vehicle changes to my exemption, and/or if I require a replacement decal. I also understand that I need to provide this updated information to TReO prior to crossing the bridge. 4. My Exemption Renewal (occuring every 5 years) has been approved and registered in the TReO System. I understand that if I have not provided a new, complete application (with new supporting documents) that has been approved prior to the expiration date, I am still responsible for paying any tolls and fees charged to my account. CHECK LIST - ALL REQUIRED DOCUMENTATION MUST BE SUBMITTED WITH THIS APPLICATION FORM Proof of exemption documents (see page 2) Current copy of ICBC registration papers To verify the information provided in this application, I give permission to TReO to access my personal information with the Ministry of Social Development, contact Service Canada regarding the status of my CPP Disability Pension or contact my physician as listed in Part 2. Applicant s Signature: I have read and agree with the preceding requirements and conditions. Please send your completed application and required documentation to TReO: Mail: TReO Customer Service Centre Fax: Woolridge Street [email protected] Coquitlam BC V3K 0B9 Phone: TREO (8736) Alternatively, you can drop off this form in-person at one of our Customer Service Centres. Please visit for locations and hours of operation. PWD Page 4 of 4

5 To be completed by your physician: Part 2 Physician Certification Qualification: a permanent disability that may result in the inability to: - carry out personal care activities such as preparation, serving and eating of meals - be mobile without personal assistance - manage personal affairs without supervision Attention Physicians: Please confirm that the applicant named on Part 1 of this form meets the qualifications for permanent disability listed above. Ensure that your submission/approval of this application is for a patient who has a permanent disability only. I have access to this applicant s medical records and hereby certify that Name of Applicant (Name that appears on ICBC registration papers) has a disability that impedes this person s normal daily activity (eg. preparation, serving and eating of meals, mobility, managing personal affairs, etc). Certification: I hereby certify that, to the best of my knowledge, the above information is true and correct. Signature of Physician: (MM/DD/YYYY) Name of Physician: (please print) Address: Physician Stamp Required Phone Number: PWD Page 1 of 1