If you have any questions or need help in completing this form, please call toll free at 1-866-764-2026.
You can also email us at info@benefitpeople.ca

(Please do not mail this page in with your health insurance application if it prints in a separate page)
 
FOR BEST RESULTS USE INTERNET EXPLORER 4.0 (OR HIGHER) TO PRINT THIS APPLICATION
 

    

HEALTH PLAN APPLICATION
 PAGE 1
 *All applicants must complete parts A, B, C, D,.
 *All applicants must sign and complete 
  Applicant’s Declaration

AIR MILES#: | 8 |__|__|__|__|__|__|__|__|__|__|

Sub-Broker ID (Office Use Only): ___________

Agent ID

flexCARE®
Manulife Financial

For Manulife Financial Use Only.

Keyed ______________________________

Approved ___________________________
PART A - GENERAL INFORMATION
Applicant’s Last Name:
 
 __________________________ 		First Name:

 ________________________________ 		 Initial:
 
 ________		 Government Health Card Number #:

| _ |_  |_  |_  | _ |_  | _ |_  |_  |_  |
Apt. Number:
 
____________		 Street Number & Name:

 ________________________________		 Home Telephone:

 (        ) ______   __________
City or Town:
 
__________________________		 Province:

_________________________________		 Postal Code:

__________		  Occupation:

______________________________
 Marital Status:   Single    Married   Other _________________________________________________________________
Applicants Office Telephone: (         ) ______  ______________ Co-Applicant's Office Telephone: (         ) ______  ______________
Applicant's Fax: (         ) ______  ________________________ Co-Applicant's Fax: (         ) ______  ________________________
Applicant's Email: _____________________________________ Co-Applicant's Email: _____________________________________
If additional information is required during regular business hours, may we contact you by phone?       HomeOffice
Are you now covered or did you have previous coverage with Manulife Financial?  Yes No
 
    If "Yes" Give Group and Identification Numbers:  | _ | _ | _ | _ | _ | _ | _ | _ |      | _ |  _| _ | _ | _ | _ | _ | _ | _ | _ | _ |

    Date Benefits ended? (mm/dd/yyyy): _______________________________ 
Is this application intended to replace your current Manulife Financial coverage? Yes  No
Have you been covered by any other health plan?  Yes  No
 
     If Yes, Where? ___________________________________________      Date benefits ended? ___________________________
Beneficiary designation for payment of Accidental Death & Dismemberment benefit (in the case of death, if no beneficiary designation is made, benefits will be payable to the estate):
Name: ___________________________________________ Relationship to Applicant: __________________________________
If you designate a beneficiary under the age of 18, benefits will be paid into court, unless a trustee is appointed
 Name of Trustee: __________________________________  Relationship to Applicant: ___________________________________
Signature of Applicant:__________________________________________          Dated (mm/dd/yyyy):  _______________________

    

HEALTH PLAN APPLICATION 
 PAGE 2
  *All applicants must complete parts A, B, C, D,.
  *All applicants must sign and complete Applicant’s Declaration
PART B – PLAN CHOICE
Remember: Your Plan Choice applies to all family members  except Lifeline.
I / We apply for:                           
CORE PLANS
 ADD-ONS 
STAND-ALONES 
    (Available only with a Core plan) (Available without a Core plan)
 DentalPlus™ Basic*  Travel + 8days
(Not available with Combo PlusStarter)		  Extended Health Care (EHC) Basic
 DentalPlus™ Enhanced*  Travel + 21days
(Not available with Combo PlusStarter)		  Extended Health Care (EHC) Enhanced
 DrugPlus™ Basic    Accidental Death & Dismemberment
        Enhanced * 		 Hospital Basic
 DrugPlus™ Enhanced  Extended Health Care Enhanced  Hospital Enhanced
 ComboPlus™ Starter*  Hospital Basic  Hospital Cash
 ComboPlus™ Basic  Hospital Enhanced  Catastrophic Coverage
 ComboPlus™ Enhanced  Hospital Cash  
   Catastrophic Coverage  
   Vision Enhanced
 (Not available with Combo PlusStarter)		  
 * These plans do not require completion of the Medical Questionnaire of this application.
  For Lifeline Personal Response Service, contact us and request a Lifeline application.
PART C – INDIVIDUALS TO BE COVERED
First Name Last Name Health Card No Code Sex Birth date
(mm/dd/yyyy)		 Age SMOKER?
 # of Cigarettes Daily
 
__________________
APPLICANT
________________________
    		|__|__|__|__|__|__|__|__|__|__| 00        

__________________
CO-APPLICANT 		________________________
  		|__|__|__|__|__|__|__|__|__|__| 01        

__________________
DEPENDANT CHILD 		________________________
  		|__|__|__|__|__|__|__|__|__|__| 02        

__________________
DEPENDANT CHILD 		________________________
  		|__|__|__|__|__|__|__|__|__|__| 02        

__________________
DEPENDANT CHILD 		________________________
  		|__|__|__|__|__|__|__|__|__|__| 02        

__________________
DEPENDANT CHILD 		________________________
  		|__|__|__|__|__|__|__|__|__|__| 02        
If you require more space to complete any part of this application, please attach a separate sheet.

    

HEALTH PLAN APPLICATION 
 PAGE 3
  *All applicants must complete parts A, B, C, D,.
  *All applicants must sign and complete Applicant’s Declaration
PART C (cont'd) – INDIVIDUALS TO BE COVERED 
 

HEIGHT (cm/inch)

WEIGHT
(lbs/kg)		 WEIGHT CHANGE IN 
LAST YEAR

GAIN              LOSS


REASON
APPLICANT:                         |   
CO-APPLICANT:                         |   
DEPENDANT CHILD:                         |   
DEPENDANT CHILD:                         |   
DEPENDANT CHILD:                         |   
DEPENDANT CHILD:                         |   
PART D – BILLING OPTIONS
Initial Payment:          I hereby authorize Manulife Financial to debit the initial 2 months premium, $___________,
                                      from my:    Financial Services Account        Credit Card Account
 
Subsequent Payments:    Will be made by:
 
       Pre-Authorized Payment Plan From my Financial Institution (Please also complete PART E below) 
               
                 PAP Billing Frequency:    Monthly    Semi-annually (2% Discount)   Annually (4% Discount) 
       
       Credit Card (Please also complete PART E below)               
 
                Visa   MasterCard   Amex    Account #  __________________________ Expiry Date (mm/yyyy) _________
                    
                Cardholder:__________________________________ Signature of Cardholder:__________________________________
                                (if other than Applicant or Co-applicant)                
                
                Credit Card Billing Frequency:    Monthly    Semi-annually   Annually 

       Direct Billing                    

                 Direct Billing Frequency:    Semi-annually (2% Discount)     Annually (4% Discount) 

Important: For verification purposes we require a VOID cheque if a payment is being withdrawn from your financial services account.

Please note: Premium discounts are not available for Credit Card payment options.
 
Manulife Financial will give me/us at least 30 days written notice in advance, should there be a change in either the amount or premium due date.  Manulife Financial may terminate coverage if a withdrawal is refused for any reason and the financial institution shall in no way be held liable should such an event occur.  A $25.00 NSF fee will be charged for all NSF transactions.

    

HEALTH PLAN APPLICATION 
 PAGE 4
  *All applicants must complete parts A, B, C, D,.
  *All applicants must sign and complete Applicant’s Declaration
PART E – FINANCIAL INSTITUTION (FOR PRE-AUTHORIZED PAYMENT PLAN)
 
Name of account holder(s) if different from applicant: _____________________________________________________________
 
Financial Institution: ________________________________________________________________________________________
 
Address: ________________________________________________________________________________________________     

City/Town: _______________________________________________________________________________________________

Type of Account:Personal Chequing  Chequing/Savings  Savings  Current  Direct Deposit Account   Other

Joint Accounts: Is this a joint account requiring only one signature?   Yes  No
If more than one signature is required on withdrawals issued against the account, both account holders must sign this authorization.

Non-Chequing Accounts: Since approval from my/our financial institution is required for pre-authorized payments from accounts with no chequing privileges, I/we have made prior arrangements to allow for pre-authorized payments from my/our account. Enclosed is a withdrawal slip that has been stamped by my/our financial institution allowing withdrawals to be made from my/our non-chequing account. This authorization shall remain in effect unless 30 days written notice is given to Manulife Financial requesting cancellation by the account holder.

For Pre-Authorized Payment and Credit Card billing options: I/We hereby authorize Manulife Financial to withdraw premium payments from my/our account on or about the first business day of the month. This authorization shall remain in effect unless 30 days written notice is given to Manulife Financial requesting cancellation by the account holder.
 
Manulife Financial will give me/us at least 30 days written notice in advance should there be a change in either the amount or premium due date. Manulife Financial may terminate coverage if a withdrawal is refused for any reason and the financial institution shall in no way be held liable should such an event occur. A $25.00 NSF fee will be charged for all NSF transactions.
Signature of account holder:  
________________________________________________________________________
Second signature if joint account:  
________________________________________________________________________

    

MEDICAL QUESTIONNAIRE - PAGE 5
Based on your or your family's medical history, coverage may be declined or modified to exclude certain conditions or be given a higher premium.  Coverage will commence on the first of the month following approval of this application.
*All applicants must sign and  complete the Applicant's Declaration.
SECTION A – TREATING QUALIFIED HEALTH CARE PRACTITIONER


Must be completed for all plans except DentalPlus and ComboPlus Starter.
  
Name and Address of Present Primary HealthCare Provider/Physician (who holds the majority of your medical records) and any other Qualified Health Care Practitioners consulted (if none, print "none"):

  Applicant Co-Applicant Dependant(s)
Name of Primary Health Care Provider:        
Address of Primary Health Care Provider:       
Last Consultation Date:       
Reason:      
Diagnosis made:      
Treatment given:      
Name and Address of any other Qualified Health Care Practitioner consulted:
  
 
SECTION B – PREFERRED UNDERWRITING QUESTIONNAIRE

Must be completed for all plans except DentalPlus and ComboPlus Starter

These questions are intended for streamlining applicants.

Have you, your co-applicant or any listed dependant:
 
1.  Been disabled and/or unable to perform normal daily activities from any cause for at least 2 consecutive weeks within the last
     5 years?   Yes  No
 
2.  Consulted or been advised to consult a Qualified Health Care Practitioner about or had any known indication of a medical 
     condition within the last year?   Yes  No

3.  Sustained any injury or been treated for any medical condition that requires or has required the services of a Qualified Health
     Care Practitioner at least once per year within the last 2 years?    Yes  No

4.  a)  Been advised to use a medication or treatment for a chronic and/or recurring medical condition;
     b)  Used any medication or treatment for 20 or more days within the past year;
     c)  Expect to use any medication or treatment within the next 3 months?    Yes  No                        
          Note: Medications used for birth control or to treat minor ailments like cold or flu are not to be considered "Yes" when
          answering this question.
 
5.  Been diagnosed with any major medical illness, condition or disease, or been advised by a Qualified Health Care Practitioner
     to have an investigation, surgery or seek hospitalization?     Yes  No
 
Note: Additional medical information may be required to underwrite your application. 

  If any questions above are answered "Yes", please complete Sections C and D below.

    

MEDICAL QUESTIONNAIRE - PAGE 6
Based on your or your family's medical history, coverage may be declined or modified to exclude certain conditions or be given a higher premium.  Coverage will commence on the first month following approval of this application.
*All applicants must sign and  complete the Applicant's Declaration.
SECTION C – MEDICAL CONDITIONS
Must be completed for all plan choices except DentaIPlus and ComboPlus Starter.
1. Have you, your co-applicant or any listed dependant ever consulted a Physician or Health Care Practitioner about, been treated
    for, or had any known indication of: (check yes or no to all questions)
a) High Blood Pressure, Stroke, T.l.A. or
    Chest Pain 		 Yes  No i) Arthritis/Rheumatism  Yes  No
b) Heart, High Cholesterol or Circulatory
    Disorder, Dizziness, Fainting or Blood
    Disorder		  Yes  No   j) Cancer, Tumor or any Growth  Yes  No
c) Back, Joint or Musculoskeletal Pain
    or Disorder 		 Yes  No k) Skin Disorder  Yes  No
d) Digestive System Disorder, Liver
    Disease/Disorder including Hepatitis		  Yes  No 1) Infertility/Reproductive Disorder/Menopause   Yes  No
e) Nervous, Mental, Emotional Disorder  Yes  No m) Bladder/Kidney Disorder or other Genitourinary
     Disorder		  Yes  No
f) Alcohol/Drug Abuse  Yes  No n) Headaches/Migraines  Yes  No
 g) Asthma/Allergies/Respiratory Disorder
      or Shortness of Breath   		  Yes  No o) Diabetes/Endocrine Disorder   Yes  No
h) Immune Disorder including testing for
    Acquired Immune Deficiency Syndrome
    (AIDS), Human Immunodeficiency
    Syndrome (HIV)		  Yes  No p) Eye or Ear Disorder  Yes  No
    q) Other Condition/Disease/Disorder

Please specify:__________________________		  Yes  No
2. Have you, your co-applicant or any listed dependant ever been treated or hospitalized for any Physical Impairments, Congenital
    Abnormality, Medical Condition, Disease or Disorder not stated above?
    Applicant:Yes No  Co-applicant:Yes No   Dependant Child: Yes No
3. Have you, your co-applicant or any listed dependant ever been advised to have an investigation, hospitalization or surgery which
    has not been completed?    Applicant:Yes No        Co-applicant:Yes No          Dependant Child: Yes No
4.  If answer is "yes" to any question in Section C, give explanation below:
Ques-
tion
No.		 Proposed Insured with Condition Name of Illness/Condition Date
Diagn-
osed		 Duration Name & Address of Qualified Health Care Practitioner and/or hospital providing treatment Results of treatment & extent of recovery
             
             
             
             

    

MEDICAL QUESTIONNAIRE - PAGE 7
Based on your or your family's medical history, coverage may be declined or modified to exclude certain conditions or be given a higher premium.  Coverage will commence on the first month following approval of this application.
*All applicants must sign and  complete the Applicant's Declaration.
SECTION D – MEDICATIONS AND TREATMENTS
                                  Must be completed for all plans except DentalPlus and CombPlus Starter
5. Are you, your co-applicant or any listed dependant currently using or expect to be using medication or serum in the next 3 months?
    (v yes or no)  Yes No            If yes, provide details below: 
Proposed insured  Name of the drug/
medication/serum/
treatment 		Condition being treated  Strength and daily dosage of the drug / medication /  serum Monthly cost Length of time
on this drug / 
medication / 
serum/treatment
           
           
           
           
 
6. Are you, your co-applicant or any listed dependant pregnant?  Yes No   
     If yes:  Name________________________________________________ Due Date (mm/dd/yyyy): _________________________
Note: Additional medical information may be required to underwrite your application.
SECTION E – CATASTROPHIC MEDICAL QUESTIONNAIRE
Must complete sections A, B, C, D when applying for Catastrophic coverage
(Available either as an Add-On or Stand-Alone coverage)

1. Have you, your co-applicant or dependants, natural parents, brother(s), sister(s), either living or dead, ever suffered from any of
    the following conditions: Heart Disease, Stroke, Cancer (specify type), Diabetes, Kidney Disease, Mental Illness, Alcoholism,
    Huntington's Chorea, Amyotrophic Lateral Sclerosis (Louis Gehrig's Disease), Motor Neuron Disease, Multiple Sclerosis, Alzheimer’s
    or any other hereditary disease?   Yes No.  If yes, please complete the section below:

Name of Proposed Insured Relationship to
Proposed
Insured 		Condition Age at
onset 		Age if
living 		Age at
death 		Cause of death
             
             
             
             

2. AVOCATION AND SPORTS
     Have you, your co-applicant or any listed dependant participated in the last 3 years or expect to participate in, any activities of a
     hazardous nature including, but not limited to: Motorized Vehicle Racing, Skin or scuba Diving, Sky Diving, Mountain Climbing,
     Hang-Gliding, or any other hazardous sports or activities?    Yes  No

     If yes, please indicate the name of the avocation(s)/sport(s) and person to whom it applies:
      _______________________________________________________________________________________________
     A supplemental questionnaire will be sent to you for completion.

3. Do you intend to fly other than as a passenger on a commercial airline, or have you flown other than as a passenger on a
     commercial airline within the past 3 years?     Yes  No
      If yes, please indicate the name of the person to whom it applies:
      _______________________________________________________________________________________________
     A supplemental questionnaire will be sent to you for completion.

4.  DRIVING RECORD
     Have you, your co-applicant or dependant in the last 3 years had your driver's license suspended, revoked or had 3 or more
     moving violations?   Yes  No    
     If yes, please provide: 
     Name: _____________________________________   Drivers License Number: ________________________________
     Details: _________________________________________________________________________________________
                  _________________________________________________________________________________________
                  _________________________________________________________________________________________

    

APPLICANT'S DECLARATION - All Applicants Must complete This Section
This Plan is underwritten by The Manufacturers Life Insurance Company.
 Check here  if you do not wish to receive further information and material on Manulife Financial's products.

NOTE: THE INFORMATION PROVIDED ON THIS FORM IS CONSIDERED CONFIDENTIAL. The statements contained herein are true and complete and together with any other forms signed by me/us in connection with this application, form the basis for any Agreement issued hereunder.  •If the plan I/we have selected is medically underwritten, I/we hereby authorize any licensed physician, medical practitioner, hospital, clinic, medical facility or organization which has records of my/our health to release such information to Manulife Financial. I/We understand and agree that information relating to the administration of under this plan may be provided to third parties to whom access has been granted or those authorized by law. A photocopy of this signed authorization shall be as valid as the original. •I/We understand and agree that any injury that occurred on or before the date of this application or any medical condition, the signs of which first appeared on or before the date of this application may not be covered by the Agreement.  Failure to disclose such information could result in denial of a claim and the cancellation or modification of this Agreement.  Manulife Financial reserves the right to recover any claims paid due to the applicant's failure to disclose an injury or medical condition that existed on or before the date of this application.  • I/We understand and agree that coverage shall not become effective until the first of the month following final approval.  • Unless I/We have checked the box above, I/we consent to Manulife Financial providing me/us, from time to time, with further information and material regarding its products.

Signature of Applicant:_________________________________ Signature of Co-applicant:_________________________________

Dated:_________________
                (mm/dd/yyyy)
   

    

If you have any questions or need help in completing this form, please call toll free: 1-866-764-2026
 
For the fastest possible coverage please fax your application
  
Mail To:
 Benefit People
Park Place Corporate Centre
15 Wertheim Crt., Suite #802
Richmond Hill, Ontario
L4B 3H7
Fax To:
Benefit People
 905-764-0051
(Note that you must still mail in the original application, along with a void cheque if paying by monthly withdrawal)