CRITICAL ILLNESS CONVERSION PACKAGE

Transcription

1 CRITICAL ILLNESS CONVERSION PACKAGE Converting your Critical Illness Coverage from the Group Policy to an Individual Policy Act now to avoid an interruption in coverage. This brochure sets forth the conditions under which a person no longer eligible for insurance under their Group Policy underwritten by ACE INA Life Insurance may convert to an individual policy affording Critical Illness Benefit. How to Apply Complete the enclosed application and mail it along with your cheque (payable to ACE INA Life Insurance) for the annual premium to: ACE INA Life Insurance York Street Toronto, ON M5J 2V5 Page 1 of 7

2 Application for Conversion to an Individual Critical Illness Insurance Policy TO BE COMPLETED BY EMPLOYER (PLEASE PRINT) Master Policy or Reference Number: Policyholder Name: Name of insured employee: Original Date of Coverage: (last name, first name) On the above person terminated employment or otherwise became ineligible for coverage under the Group Critical Illness Policy underwritten by ACE INA Life Insurance. Prior to that date the above individual was insured for $ (Mandatory) $ (Optional) The individual s dependent family members: were not included *If they were included please fill-in the applicable information below: Spouse: Last Name First Name Birthdate Sex (m/f) *were included Effective Date of Coverage Amount Insured for Child(ren) Amount Insured For: $ Last Name First Name Birthdate Sex (m/f) Child(ren) (< age 21) Full-time Student (< age 25) Disabled (> age 25) Effective Date of Coverage Signed: Dated: Title: Phone Number: TO BE COMPLETED BY PROPOSED INSURED (PLEASE PRINT) Application is hereby made for conversion to an individual Critical Illness Insurance Policy. Full Name: (last name, first name) Address: City: Province: Postal Code: Phone Number: Daytime: Evening: Date of Birth: Smoker Non-smoker Non-Smoker means someone who has not smoked cigarettes, cigarillos, cigars, pipe or chewing tobacco or used any nicotine products (patch, gum, etc.) for twelve months or more prior to the date of enrollment. Page 2 of 7

3 I desire to convert I desire to convert Spouse: Smoker $ (maximum $25,000) of my employee Critical Illness Insurance coverage. $ (maximum $25,000) of my spousal Critical Illness Insurance coverage. Non-smoker I desire to convert $ (maximum $5,000) of my *dependent Critical Illness Insurance coverage. * coverage may only be converted if either the employee or spousal coverage is being converted. Conversion Options: Option A (Cancer only Coverage) Option B (Spectrum Coverage) Full name of beneficiary and state relationship to you: I have enclosed my cheque (made out to ACE INA Life Insurance) in the amount of $. (Your application including a cheque for the annual premium payment must be mailed within 31 days of eligibility to convert. If selecting Option B, you must also include the Critical Illness Statement of Good Health.) I have read the above statements and agree that they are accurate and complete to the best of my knowledge and belief. I understand that this insurance will be issued in reliance upon such statements. Signature of Proposed Insured: Date: Page 3 of 7

4 Who May Convert? You may elect to convert all or part of your Critical Illness benefit, subject to a maximum of $25,000, as a result of: Termination of employment; Termination of your eligibility for any reason (except for age or termination of the group plan under which you are insured); Provided you apply within 31 days after your group insurance terminates and pay the premium for the new policy at the rate then in effect for your attained age. Conversion Options Option A Cancer Only - Medical certification or evidence is NOT required. On the date of termination of employment or during the 31 day period following termination of employment, an insured person may convert his/her insurance to an individual insurance policy of ACE INA Life Insurance. The individual policy will be effective on the date that coverage under the group policy ceases. The premium will be the same as an insured person would ordinarily pay when applying for an individual policy at that time. Application for an individual policy may be made at any office of ACE INA Life Insurance. The amount of Critical Illness insurance benefit converted to shall not exceed that amount issued during employment up to an all policies combined maximum of $25,000. Cancer: Means a malignant tumor characterized by the uncontrolled growth and spread of malignant cells and invasion of tissue. This includes Leukemia, Hodgkin s Disease and invasive melanoma but does not include: - carcinoma in situ - Kaposi's Sarcoma or other AIDS related cancers and cancer in the presence of human immunodeficiency virus (HIV) - Skin cancer or melanoma that is not invasive and has not exceeded.75 millimeters in depth. - Prostate cancer diagnosed as T1N0M0 or equivalent staging. A physician certified as an Oncologist must confirm diagnosis in writing. Option B Spectrum Coverage - Medical certification or evidence IS required if coverage was accepted previously on a Guaranteed Issue basis. Please complete the Critical Illness Statement of Good Health attached. On the date of termination of employment or during the 31 day period following termination of employment, an insured person may convert his/her insurance to an individual insurance policy of ACE INA Life Insurance, subject to medical evidence of insurability. The individual policy will be effective on the date that coverage under the group policy ceases. The premium will be the same as an insured person would ordinarily pay when applying for an individual policy at that time. Application for an individual policy may be made at any office of ACE INA Life Insurance. The amount of Critical Illness insurance benefit converted to shall not exceed that amount issued during employment up to an all policies combined maximum of $25,000. For information on the covered conditions, please see your current benefit wording. Page 4 of 7

5 The Converted Policy On the date of termination of employment or during the 31-day period following termination of employment, an insured person may convert his/her insurance to an individual insurance policy of ACE INA Life Insurance. The individual policy will be effective on the date that coverage under the group policy ceases. The premium will be the same as a person would ordinarily pay when applying for an individual policy at that time. Application for an individual policy may be made at any office of ACE INA Life Insurance. The amount of insurance benefit converted to shall not exceed that amount issued during employment up to an all policies combined maximum of $25,000. Subject to the Provisions entitled "Grace Period", "Termination by Insured" and "Payment of Renewal Premiums", this policy is renewable subject to the consent of ACE INA Life Insurance as of each renewal date upon timely payment of the premium at ACE INA Life Insurance's premium rate in effect at the time of each such renewal but this policy will not be renewed on or after the policy anniversary next following the Insured's attainment of age 65. This policy does not cover loss caused by or resulting from any one or more of the following: A. intentionally self-inflicted injuries, suicide or any attempt thereat, while sane or insane; B. declared or undeclared war or any act thereof; C. for injury or sickness, other than one of the Insured Conditions, even though such injury or sickness may have been complicated by one of the Insured Conditions; D. a complication of Human Immunodeficiency Virus (HIV) infection or any variance thereof including AIDS and AIDS Related Complex; E. the use, existence or escape of nuclear weapons, material or ionizing radiation from or contamination by radioactivity from any nuclear fuel or waste from the combustion of nuclear fuel; F. the commission or attempted commission by the Insured Person of any act which if adjudicated by a court would be an illegal act under the laws of the jurisdiction where the act was committed; G. misuse of medication or the abuse of drugs or intoxicants; H. any Pre-existing Medical Condition, except where coverage has been in effect for a period of twenty-four consecutive months following the Insured Person s effective date of coverage. Note: the original effective date of the applicant s Group Critical Illness policy with ACE will be used to determine any time accumulated toward the Waiting Period and/or Pre-existing Medical Condition under this conversion policy. Selection of Principal Sum Conversion The amount of insurance benefit converted shall not exceed that amount issued during employment up to an all policies combined maximum of $25,000. Annual Cost per $5,000 of Principal Sum Using the Rate Table below, please determine your annual premium for the converted Principal Sum Amount you selected ($25,000 maximum) and enclose a cheque for that amount (paid to the order of ACE INA Life Insurance ) with this completed Critical Illness Conversion Package. Page 5 of 7

6 CRITICAL ILLNESS CONVERSION RATE TABLE ANNUAL COST PER $5,000 How to calculate your annual premium: MALE Age Band Non-Smoker Smoker Under 25 $ 7.56 $ to 29 $ 9.30 $ to 34 $ $ to 39 $ $ to 44 $ $ to 49 $ $ to 54 $ $ to 59 $ $ to 64 $ $ FEMALE Age Band Non-Smoker Smoker Under 25 $ 5.25 $ to 29 $ 8.70 $ to 34 $ $ to 39 $ $ to 44 $ $ to 49 $ $ to 54 $ $ to 59 $ $ to 64 $ $ Example: Female, 50 years old, non-smoker, converting $10,000 of Critical Illness Insurance Gender Age Smoker Amount of Insurance Annual Premium Band Status being Converted F 50 to 54 Non $10,000 2 x $79.05 = $ Page 6 of 7

7 GROUP INSURANCE PLAN C R I T I C A L I L L N E S S S T A T E M E N T O F G O O D H E A L T H INSURED INFORMATION (Please print) Last Name Master Policy/Reference # First Name Company Telephone # Home Address City Province Postal Code Birthdate DEPENDENDENT INFORMATION (Please print) - (Please list minor dependents named in the application if applicable) Relation Last Name First Name Birthdate Sex (m/f) Child(ren) (< age 21) Full-time Student (< age 25) Disabled (> age 25) Spouse STATEMENT OF GOOD HEALTH I have read and understood the information related to the coverage, particularly the Exclusions and the Pre-Existing Conditions Clause. I declare that neither I, or my spouse or any of my named minor dependents (if applicable), have ever been diagnosed with, or sought medical advice on, any of the covered conditions, nor have I, or any of my named minor dependents, been diagnosed with arthritis, osteoporosis, cancer, diabetes, heart disease, hepatitis, advanced ophthalmic disease, advanced loss of hearing, chronic or progressive kidney, lung or liver disease, transient ischemic attack (TIA) or tested positive for AIDS/HIV. AUTHORIZATION Employee signature Signed at this day of 20 Spouse s signature (if applicable) Signed at this day of 20 Privacy Statement: When you apply to enroll in the ACE INA Group Insurance Plan, underwritten by ACE INA Life Insurance ( ACE Life ), the information in ACE Life s existing insurance files and the information requested on your application is required by ACE Life, its reinsurers and authorized agents to process your application (and if approved), administer your insurance policy, assess claims and investigate misrepresentation. ACE Life will create a file with your insurance information, and in the event of a claim, with such information as ACE Life obtains from you and other sources, for the purpose of considering you claim and administering benefits under the Plan. Access to this file will be restricted to those ACE Life employees, authorized agents and reinsurers who require access to administer the Plan and process claims and persons authorized by law. You may request to review your personal information in this file or request to make a correction by writing to: The Privacy Officer; ACE INA Life Insurance, York Street, ON, M5J 2V5 Information about your insurability and your dependents insurability will be treated as confidential. Page 7 of 7