4 Renewable for life 4No medical exam 4Possibility of coverage from day one. 4Available to insureds ages 1 to 79 years old

Transcription

1 4Hospital Benefit 4Refund of Premiums upon Death 4Accidental Death, Dismemberment or Loss of Use 4Accidental Fracture and Complementary Medical Care as a result of an Accident 4Refitting as a result of an Accident 4Medical and Legal Assistance Services 4 Renewable for life 4No medical exam 4Possibility of coverage from day one 4Available to insureds ages 1 to 79 years old 4Level premiums based on age at the time of purchase

2 EXCELLENCE to Suit Your Needs The Excellence Life Insurance Company was incorporated in Quebec in In the past ten years, the company s total assets have grown from $2 million to over $50 million. Eligibility To be eligible for insurance, the proposed Primary Insured must be at least one year of age but less than 80 years of age. At the time of purchase, the proposed Primary Insured must not be hospitalized or awaiting Hospitalization or an operation and must not have been hospitalized for more than 30 days for a Sickness in the past 12 months. Moreover, the proposed Primary Insured must not be HIV positive and must not suffer from any of the following Sicknesses: multiple sclerosis, kidney failure, cystic fibrosis or muscular dystrophy. Hospital Benefit in the event of an Accident or Sickness (obligatory coverage) This coverage provides for payment of a daily benefit for Hospitalization of at least 18 hours as the result of an Accident or Sickness, not to exceed a lifetime maximum period of 3 years. For benefits to be payable, the Hospitalization must be medically necessary. Daily Benefit Minimum $20 Maximum $100 Waiting Period Option 1 Accident none Sickness none Option 2 Accident 3 days Sickness 3 days The Hospital Benefit includes the following benefits at no extra charge: Double Benefit Double the daily benefit for Hospitalization outside the province of residence provided the Hospital in question is over 50 km from the primary residence of the Primary Insured for a maximum period of 30 days per Hospitalization. Double the daily benefit for Hospitalization due to cancer or infarction or when the Primary Insured is hospitalized in the intensive care unit for a maximum period of 30 days per Hospitalization. Day Surgery Benefit A daily convalescence benefit of 3 days immediately following the date on which the Primary Insured undergoes Day Surgery. The maximum benefit payable is equal to 4 days including the day of surgery. Home Convalescence Benefit A convalescence benefit of 3 days after any Hospitalization period of 15 days or less giving rise to benefit entitlement. A supplementary convalescence benefit for each day in excess of the 15th day of Hospitalization, when the Primary Insured is deemed to be in a state of Total Disability upon medical recommendation immediately after a Hospitalization period of over 15 days, subject to a maximum period of 60 days of Hospitalization. Transportation Expense Allowance A transportation expense allowance for out-patient treatment recommended by a Physician further to a Hospitalization giving rise to benefit entitlement. The allowance is $25 per visit, not to exceed a lifetime maximum of $500. 2

3 Convalescence Centre Benefit A daily benefit for a stay in a convalescence centre recognized by the government health insurance board in the Primary Insured s province of residence when the stay is prescribed by a Physician, subject to a maximum of 30 days per event. Ambulance Expenses Reimbursement of ambulance services at a rate of $100 per Accident or Sickness, subject to a maximum of $500 per year. Limitations No benefit shall be payable further to Hospitalization for pregnancy, childbirth or miscarriage in the 9 months immediately following the effective date or the reinstatement of the contract and the coverage. The Hospital Benefit is subject to a maximum lifetime period of 3 years. This coverage terminates upon the death of the Primary Insured. Refund of Premiums upon Death (optional coverage) If the Primary Insured obtains this coverage at age 55 or under, this coverage provides for the refund of all premiums paid for the Hospital Benefit coverage upon his or her death. If the Primary Insured obtains this coverage at age 56 or over, the refund will be limited to 50% of the premiums paid for the Hospital Benefit coverage upon his or her death. In all cases, any claims paid under the Hospital Benefit coverage will be deducted from the premium refund. This coverage terminates at the 80th birthday of the Primary Insured. Accidental Death Dismemberment or Loss of Use (optional coverage) In the event of the Primary Insured s Accidental Death, the available sums insured are $25,000 and $50,000, subject to the following restrictions: Age at Death Age 69 or under $50,000 Age 70 or over $25,000 Maximum Sum Insured In the event of Accidental Dismemberment or Loss of Use, benefits are payable as described in the table below, based on the selected sum insured: Loss Loss of sight of both eyes Loss of both hands or both feet Loss of one hand and one foot Loss of one hand and sight of one eye 100% Loss of one foot and sight of one eye Loss of hearing and speech Loss of one arm or one leg 75% Loss of one hand or one foot Loss of sight of one eye or hearing or speech 50% Loss of one toe or one finger 10% Special Benefits Included Education Benefit Percentage of Sum Insured In the event of the Accidental Death of the Primary Insured, every Dependent child who is a full-time student at a college or university will receive $1,000, to a maximum of $4,000 per family. Occupational Requalification Benefit If an Accident results in the death of the Primary Insured and, as a result, his or her Spouse must find work, the Insurer will cover up to $5,000 for reasonable and necessary expenses for the Spouse s occupational requalification if he or she does not hold a job at the time of the Primary Insured s death. 3

4 Seatbelt Benefit If the Primary Insured sustains an Injury resulting in Loss while he or she is travelling in a vehicle as the driver or a passenger and is wearing a correctly secured seatbelt, his or her sum insured will be increased by 10%. Actual wearing of the seatbelt must be confirmed in the official Accident report or confirmed by the investigating officer. Accidental Fracture and Complementary Medical Care as a result of an Accident (optional coverage) Limitations Any Loss prior to the effective date of the contract or sustained in a previous Accident shall not be considered in the payment of this benefit. The maximum amount payable for all Losses sustained within 365 days of the Accident shall not exceed the maximum sum insured as indicated in the table above. If, as the result of a single Accident, the Primary Insured sustains several Losses listed above, benefits shall be payable for only one such Loss, that is, the Loss which represents the highest benefit amount. The maximum benefit payable to the Primary Insured is $50,000 before age 70 and $25,000 thereafter. Any reduction in the amount of insurance coverage due to age applies only at the date of renewal that follows the birthday of the Primary Insured. Accidental Fracture This coverage provides for payment of a lump sum if the Primary Insured sustains an Accidental Fracture. The Fracture must be diagnosed within 30 days of the Accident. The amount payable under this coverage is based on the attained age of the Primary Insured at the time of the Accident, as indicated in the table below: Lump Sum Based on Age Age 1 Unit 2 Units Age 65 or under $5,000 $10,000 Age 66 to 75 $2,500 $5,000 Age 76 or over $1,250 $2,500 Coverage for Accidental Dismemberment or Loss of Use terminates at the 70th birthday of the Primary Insured. Based on the amount of coverage, a lump sum equal to the percentage indicated in the table below will be payable: Applicable Percentage Fracture Skull, Spine, Pelvis 100% Femur, Hip Sternum, Larynx, Trachea, Scapula, Radius, Humerus, 25% Ulna, Patela, Tibia, Fibula, Coccyx All other bones 10% Limitations The maximum amount payable for multiple Fractures shall be the highest amount payable for any one of the sustained Fractures. The Primary Insured cannot be indemnified for a same Injury under this coverage and under a coverage for Accidental Dismemberment or Loss of Use. The Accidental Fracture coverage terminates at the 80th birthday of the Primary Insured. 4

5 Complementary Medical Care as a result of an Accident If provided in Canada, this coverage provides for the reimbursement of eligible expenses at a rate of 100%, without deductible, for all of the following benefits: 4 Hospitalization in a semi-private room. Upon medical recommendation 4 Laboratory services for diagnostic purposes during treatment; 4 Private nursing care at home; 4 Artificial eyes and limbs (initial cost only); 4 Casts, slings, trusses, crutches, walkers and canes; 4Rental of the following: orthopedic devices; a manual and conventional wheelchair; a manual and conventional hospital bed; equipment to administer oxygen; 4 Any initial prosthesis (excluding eyeglasses, contact lenses, mammary or capillary prostheses). Without medical recommandation 4 The professional fees of a chiropractor, physiotherapist, osteopath, podiatrist, psychologist, speech and hearing therapist or occupational therapist, subject to a maximum of $25 per treatment and an overall maximum of $350 per Accident for all such professionals; 4 X-rays for chiropractic purposes, to a maximum of $25 per Accident; 4 Dental Accident involving natural, healthy teeth, to a maximum of $1,000 per Accident. For the purpose of determining benefits, the Primary Insured is deemed to be covered under a government or para-governmental plan that offers taxpayers health care services such as Hospitalization, medical care and other eligible services in the Primary Insured s province of residence. Sums paid by the Insurer shall in no case exceed those that would have been payable had the insured person been covered under such a plan. Moreover, this coverage reimburses medically necessary expenses incurred within 12 months of the date of the Accident. Limitations For a Primary Insured under age 70, the maximum amount of eligible expenses covered is $2,500 per Accident. For a Primary Insured age 70 or over, the maximum amount of eligible expenses covered is $500 per Accident. Expenses for Complementary Medical Care are subject to the Coordination of Benefits clause in the policy. The Complementary Medical Care as a result of an Accident coverage terminates at the 80th birthday of the Primary Insured. Refitting as a result of an Accident (optional coverage) This coverage reimburses expenses incurred for the refitting of an automobile or the primary residence where made necessary by an Accident for a Primary Insured who presents a permanent motor impairment. The lifetime maximum for this coverage is $25,000. The Refitting as a result of an Accident coverage terminates at the 80th birthday of the Primary Insured. General Exclusions Applicable to all Coverages No indemnity or benefit under this contract shall be payable for an event resulting directly or indirectly from any of the following: a) suicide, attempted suicide, intentionally self-inflicted Injury or Dismemberment, whether the Primary Insured is sane or insane; or b) Injury sustained while the Primary Insured is actively participating in a riot, an insurrection or hostilities, or Injury sustained during a war, whether declared or not; or c) commission or attempted commission of a criminal act by the Primary Insured; or d) participation by the Primary Insured in any type of flight or attempted flight while he or she is travelling aboard a craft other than as a passenger; or e) the driving of a motor vehicle by the Primary Insured while under the influence of narcotics or while his or her blood alcohol concentration exceeds the limit prescribed by law; or f) participation in a race, trial or speed contest in automobiles, on motorcycles or in any other motor vehicle; or g) intentional inhalation of gas, asphyxia or poisoning; or h) treatment undergone for cosmetic purposes. 5

6 Special Exclusions for: Accidental Death, Dismemberment or Loss of Use No indemnity or benefit under this coverage shall be payable for a Loss resulting directly or indirectly from any of the following: a) Death or Loss of Use resulting from a high-risk medical intervention is not deemed to be accidental given the Insured Person s medical condition. Complementary Medical Care as a result of an Accident No indemnity or benefit under this coverage shall be payable for a Loss resulting directly or indirectly from any of the following: a) medical care or services which the Primary Insured is entitled to receive without charge under federal or provincial legislation, or which are covered under such legislation; b) experimental care or treatment or new procedures and treatments that are not yet common practice according to the Department of Health and Social Services. Additional Assistance Services Excel Health A single phone call provides access to health professionals who are available to answer questions on topics such as: 4 health 4 sicknesses 4 diet 4 lifestyle 4 vaccines 4 medication Excel law In the course of a lifetime, certain events may require special information on topics such as: marriage, separation, divorce, children, family law, seniors rights, estate planning, contracts, housing, real estate, neighbours, work, retirement, income tax, taxation, commercial law, municipalities and governments. This general legal information is provided by experienced specialists in all confidentiality. Renewal The Insurer undertakes to renew this insurance from year to year provided the renewal premium is paid within the prescribed timeframe. Upon each renewal, the Insurer may modify the premium, based upon age of purchase, for all contracts issued and the premium will then be equal to the premium payable for a similar contract issued by the Insurer and offering the same benefits. At the date of renewal or at his or her election, the Policyholder may add or change the coverages that are part of the insurance. Note This document is a short summary of the coverages and conditions of your contract. Please refer to your personal insurance policy. It is important that you read and understand your policy. THE EXCELLENCE LIFE INSURANCE COMPANY 5055 Metropolitain Blvd. East, Suite 202, Montreal, Quebec H1R 1Z7 Telephone: / Toll-free: Fax: / Toll-free: MB-EH1E

7 EXCEL HOSPITALIZATION Application NEW APPLICATION REINSTATEMENT AMENDMENT 1 Name of representative Code GENERAL INFORMATION Last name of Primary Insured First name Social insurance number Address Postal code Telephone number (residential) Date of birth Age Gender Marital status Y M D M F single married common-law spouse divorced widowed Telephone number (office) 2 3 Are you, or have you ever been, insured by Excellence? Yes No If yes, please indicate your contract number Last name of Policyholder (if other than the Primary Insured) First name Social insurance number Address Postal code Telephone number Same or Date of birth Age Gender Relationship to Primary Insured Y M D M F 4 5 SUMMARY OF COVERAGES Hospital Benefit for Accident and Sickness $ /day Monthly premium Annual premium Waiting Period none / none 3 days / 3 days $ Refund of Premiums $ Accidental Fracture and Complementary Medical Care 1 unit 2 units $ Accidental Death, Dismemberment or Loss of Use $25,000 $50,000 $ Refitting as a result of an Accident $ Total premium: $ BENEFICIARY Last name First name Social insurance number Address Postal code Telephone number 6 Revocable Irrevocable Relationship: * A beneficiary is always revocable unless designated specifically as irrevocable, with one exception: where Quebec's Civil Code applies, a beneficiary who is married to, or in a de facto relationship with, the Primary Insured is always irrevocable unless designated specifically as revocable. TOTAL INSURANCE IN FORCE Company Year issued Amount Type Is this insurance meant to replace or modify any other insurance in force? Yes No If yes, indicate the company: METHOD OF PAYMENT CHEQUE : Please make your cheque out to The Excellence Life Insurance Company. ANNUAL : PRE-AUTHORIZED DEBIT: Beginning the of each month (1st à 28th). Same account as for contract with The Excellence Life Company. Please debit the first premium directly from my account. PERSONAL INFORMATION Any personal information that The Excellence Life Insurance Company holds or will hold with respect to you will be treated confidentially and will be kept in a file, the purpose of which is to enable you to benefit from the various financial insurance services and other similar services the company offers. This information will be consulted only by the employees of The Excellence Life Insurance Company who must do so to perform their duties. You may access your file and have any information corrected if you show that such information is incorrect, incomplete, ambiguous, outdated or unnecessary. To do so, you must apply in writing to the person responsible for access to information at the head office in Montreal. DECLARATION I, the undersigned, hereby: 1) declare that, at the time of purchase, I am neither hospitalized nor awaiting hospitalization or an operation, I have not been hospitalized for more than 30 days for a sickness in the past 12 months, I am not HIV positive and I do not suffer from any of the following sicknesses: multiple sclerosis, kidney failure, cystic fibrosis or muscular dystrophy. 2) declare that the answers and information provided in this application are true and complete and that they constitute the basis on which insurance coverage shall be established. I understand and accept that, in the event of false statement or material omission, the Insurer shall not be held to any obligation under insurance issued to me further to the approval of my insurance application. This insurance shall become effective on the date the application is accepted by The Excellence Life Insurance Company. Any false statement may result in the cancellation of the insurance. Signed at this Signature of Primary Insured Signature of Policyholder Signature of witness

8 PRE-AUTHORIZED DEBIT AGREEMENT I hereby authorize The Excellence Life Insurance Company to draw monthly cheques from my bank account (described below) equal to the monthly insurance premium. This authorization is provided in consideration of my financial institution agreeing to process debits against my account in accordance with the Rules of the Canadian Payments Association. This authorization may be cancelled at any time upon written notice from me. I acknowledge that, in order to revoke this authorization, I must give notice of revocation to The Excellence Life Insurance Company within at least ten (10) calendar days before the due date of the pre-authorized debit. I acknowledge that this authorization concerns debits in the category of personal/household in accordance with the Rules of the Canadian Payments Association. I will therefore receive, with respect to fixed amount pre-authorized debits, a written notice from The Excellence Life Insurance Company of the amount to be debited and the due date(s) of debiting, at least ten (10) calendar days before the due date of the first pre-authorized debit, and such notice must be received every time there is a change in the amount or payment date(s), including a change further to a payment instrument being returned by the bank with the stated reason of insufficient funds or a stop-payment order; or with respect to variable amount pre-authorized debits, a written notice from The Excellence Life Insurance Company of the amount to be debited and the due date(s) of debiting, at least ten (10) calendar days before the due date or every pre-authorized debit. Note that an administrative fee will be applied to payment instruments, which will be payable at the same time as the returned amount and the next regular payment. I undertake to inform The Excellence Life Insurance Company, in writing, of any change in the account information provided in this authorization prior to the next due date of the pre-authorized debit. I acknowledge that my financial institution is not required to verify that a pre-authorized debit has been made in accordance with the particulars of this Pre-authorized Debit Agreement. I further acknowledge that my financial institution is not required to verify that any purpose of payment for which the pre-authorized debit was made has been fulfilled by The Excellence Life Insurance Company as a condition to honouring a pre-authorized debit made or caused to be made by The Excellence Life Insurance Company on my account. Revocation of this authorization does not terminate any contract of insurance that exists between me and The Excellence Life Insurance Company. I may dispute a pre-authorized debit by The Excellence Life Insurance Company under any of the following conditions: (i) the pre-authorized debit was not drawn in accordance with this Pre-Authorized Debit Agreement; or (ii) I had previously duly revoked my Pre-Authorized Debit Agreement; or (iii) I did not receive the automatic advance notice required under the terms of this Pre-Authorized Debit Agreement. I acknowledge that, in order to be reimbursed, a declaration to the effect that either (i), (ii) or (iii) took place, must be completed and presented to the branch of my financial institution within ninety (90) calendar days of the date on which the pre-authorized debit in dispute was posted to my account. I acknowledge that a claim on the basis that this Pre-Authorized Debit Agreement was revoked, or any other reason, is a matter to be resolved solely between The Excellence Life Insurance Company and me when a pre-authorized debit is disputed after ninety (90) calendar days. I understand and accept this pre-authorized debit arrangement and wish to participate in it. I authorize The Excellence Life Insurance Company to disclose any personal information that may be contained in this Pre-Authorized Debit Agreement to the financial institution, as far as any such disclosure of any personal information is directly related to and necessary for the proper application of the Rules of the Canadian Payments Association. Certain recourses are available to me and I can, for example, dispute a pre-authorized debit if it is not in accordance with this authorization. To obtain the reimbursement form or for any information, you may contact your financial institution or visit For more information, you may contact our Customer Service Department at or by at service@iaexcellence.com. Signature (as it appears on the cheques) Date : D/M/Y Witness (agent or broker) Date : D/M/Y For a joint account where more than one signature is required, all account holders must sign. Signature of spouse for joint account (if necessary) Date : D/M/Y IDENTIFICATION OF PAYER AND ACCOUNT TO BE DEBITED Last name First name Address Province Postal code Name of financial institution Address Province Postal code Branch number Account number * Please attach a specimen cheque marked VOID