Group Master Application Best Doctors Global Medical Care

Transcription

1 Group Master Application Best Doctors Global Medical Care Policy Number (assigned by Best Doctors Canada Insurance Services Inc.) PART A General Applicant Full Legal Name Address (Street, City, Province, Postal Code) Number of Years in Business Type of Business Business Telephone Fax Web Address Name of Administrative Contact Title Phone Requested effective date te: Employees not actively at work as of the application date are not covered until they return to work. Plan is effective when approved in writing by Lloyd's. Please list eligible employees not actively at work as of application date. PA RT B Demographics Number of Full-time Employees Salaried Hourly Number of Key Employees Eligible for Best Doctors Global Medical Care CONTRIBUTION BASIS (%) CLASS ER EE A B C COVERED CLASSES Please list eligible job classes and describe eligible jobs if plan varies by class. (See example below.) CLASS ID CLASS DESCRIPTION ELIGIBLE JOB TITLES NUMBER OF ELIGIBLE EMPLOYEES NOTE: Minimum lives per class is 10. Minimum participation is 50% of class. Schedule of benefits can vary by Class. Please indicate Title of Class(es) eligible for coverage (can be 1 or more classes, include job titles for eligible employees. When applying for coverage employees must be full time active employees and eligible for provincial health care benefits. The maximum age for applying for coverage is seventy five (75) years of age. REQUESTED COVERAGE CLASS ID EE ONLY EE + 1 (spouse) FAMILY* A B C *NOTE: Family Coverage includes EE + spouse + dependent children (up to 18 or 24 if enrolled full-time at an accredited school) or includes EE + dependent children. Please complete Part E - Census Data (sample provided). Underwritten by certain underwriters at Lloyd's

2 PART C General Benefits Summary Plan Please complete a separate form for each Plan. Include options selected for each eligible class. Maximum Limit/Policy Year $1.0M $2.0M $5.0M $1.0M $2.0M $5.0M Maximum Limit/Year age $0.5 M $0.5 M Deductible (all services except Diagnostics) $5,000 $10,000 $20,000 $5,000 $10,000 $20,000 Deductible Diagnostics 2 Same as All Services OR $ Same as All Services OR $ Standard Room (Semi-Private) 100% OR % 100% OR % ICU/ Life Support Max $5000/day up to 90 days (room and board) Max $5000/day up to 90 days (room and board) Surgery/Orthopedic Surgery 100% OR % 100% OR % Emergency Room 100% OR % 100% OR % Diagnostic Services 100% OR % 100% OR % Cancer Treatment (Chemo/Radiation) 100% OR % 100% OR % Dialysis 100% OR % 100% OR % Maternity Inclusion of Newborn Transplants 3 $1.0 M $1.0 M Physical Therapy & Rehabilitation 100% (up to $5,000) 100% (up to $5,000) Durable Medical Equipment 100% (up to $5,000) 100% (up to $5,000) Prescription Drugs (includes Life Sustaining) 100% (up to $5,000) 100% (up to $5,000) Air Ambulance 100% (up to $45,000) 100% (up to $45,000) Ground Ambulance 100% OR % 100% OR % Repatriation (death) 100% (up to $5,000) 100% (up to $5,000) Unique Services InterConsultation, Elite Navigator, Concierge InterConsultation, Elite Navigator, Concierge Travel Benefit 1 The maximum age when applying for coverage is seventy five (75) years of age. Employees must be active full time employees eligible for provincial health care benefits. 2 Diagnostic deductible can be the same as the deductible for all services or lower 3 Lifetime maximum and includes $20,000 for living donor.

3 PART C General Benefits Summary Plan Please complete a separate form for each Plan. Include options selected for each eligible class. Maximum Limit/Policy Year $1.0M $2.0M $5.0M $1.0M $2.0M $5.0M Maximum Limit/Year age $0.5 M $0.5 M Deductible (all services except Diagnostics) $5,000 $10,000 $20,000 $5,000 $10,000 $20,000 Deductible Diagnostics 2 Same as All Services OR $ Same as All Services OR $ Standard Room (Semi-Private) 100% OR % 100% OR % ICU/ Life Support Max $5000/day up to 90 days (room and board) Max $5000/day up to 90 days (room and board) Surgery/Orthopedic Surgery 100% OR % 100% OR % Emergency Room 100% OR % 100% OR % Diagnostic Services 100% OR % 100% OR % Cancer Treatment: (Chemo/Radiation) 100% OR % 100% OR % Dialysis 100% OR % 100% OR % Maternity Inclusion of Newborn 3 Transplants $1.0 M $1.0 M Physical Therapy & Rehabilitation 100% (up to $5,000) 100% (up to $5,000) Durable Medical Equipment 100% (up to $5,000) 100% (up to $5,000) Prescription Drugs (includes Life Sustaining) 100% (up to $5,000) 100% (up to $5,000) Air Ambulance 100% (up to $45,000) 100% (up to $45,000) Ground Ambulance 100% OR % 100% OR % Repatriation (death) 100% (up to $5,000) 100% (up to $5,000) Unique Services InterConsultation, Elite Navigator, Concierge InterConsultation, Elite Navigator, Concierge Travel Benefit 1 The maximum age when applying for coverage is seventy five (75) years of age. Employees must be active full time employees eligible for provincial health care benefits. 2 Diagnostic deductible can be the same as the deductible for all services or lower 3 Lifetime maximum and includes $20,000 for living donor.

4 PART C General Benefits Summary Plan Please complete a separate form for each Plan. Include options selected for each eligible class. Maximum Limit/Policy Year $1.0M $2.0M $5.0M $1.0M $2.0M $5.0M Maximum Limit/Annum age $0.5 M $0.5 M Deductible (all services except Diagnostics) $5,000 $10,000 $20,000 $5,000 $10,000 $20,000 Deductible Diagnostics 2 Same as All Services OR $ Same as All Services OR $ Standard Room (Semi-Private) 100% OR % 100% OR % ICU/ Life Support Max $5000/day up to 90 days (room and board) Max $5000/day up to 90 days (room and board) Surgery/Orthopedic Surgery 100% OR % 100% OR % Emergency Room 100% OR % 100% OR % Diagnostic Services 100% OR % 100% OR % Cancer Treatment: (Chemo/Radiation) 100% OR % 100% OR % Dialysis 100% OR % 100% OR % Maternity Covered maternity expenses include pre-natal care, next $100,000 of the eligible medical expenses, then 100% of the balance to a maximum of $250,000. Covered maternity expenses include prenatal care, Inclusion of Newborn Transplants 3 $ $ Physical Therapy & Rehabilitation 100% (up to $5,000) 100% (up to $5,000) Durable Medical Equipment 100% (up to $5,000) 100% (up to $5,000) Prescription Drugs (includes Life Sustaining) 100% (up to $5,000) 100% (up to $5,000) Air Ambulance 100% (up to $45,000) 100% (up to $45,000) Ground Ambulance 100% OR % 100% OR % Repatriation (death) 100% (up to $5,000) 100% (up to $5,000) Unique Services InterConsultation, Elite Navigator, Concierge InterConsultation, Elite Navigator, Concierge Travel Benefit 1 The maximum age when applying for coverage is seventy five (75) years of age. Employees must be active full time employees eligible for provincial health care benefits. 2 Diagnostic deductible can be the same as the deductible for all services or lower 3 Lifetime maximum and includes $20,000 for living donor.

5 PART D Broker / Consultant Details Date Name of Agent Company Phone Fax License # / Broker Code PA RT E Census Data Please complete census data (Excel sheet attached) for eligible employees, and where applicable, eligible dependents for plans with family coverage. PART F Administration Global Medical Care (GMC) is an annual policy with Premium due and payable on an annual basis. Rates are subject to change as of the anniversary date. Cancellations can be given with 30 days written notice; however termination will occur as of the subsequent anniversary. e.g. tification on October 31st, 2012 for a plan with a January 1st anniversary date, will take effect as of December 31st, For administrative purposes, premiums can be remitted using alternative payment modes. Please indicate (X) which mode of payment is requested: Annually Semi-Annually Quarterly Monthly (subject to approval) Please indicate minimum number of hours worked per week worked for full-time employees: Hours Please indicate (X) waiting period for employees eligible for GMC coverage: Option 1: As of the first of the month, or if hired on a day other than the first of the month, as of the first day of the subsequent month. Option 2: As of the first of the month that follows three months of employment. For employees who start of the first day of the month, the waiting period is the first of the month after 3 months of employment. For plans that require employees to pay the premium (in whole or part) for spousal and/or family coverage, employees must sign and date an acknowledgement letter if spousal or family coverage is offered and declined. Employees have 30 days from the day first eligible to apply for GMC optional coverage. Please indicate the contribution required (if any) for GMC coverage:

6 PART G Declaration Payment is payable to Best Doctors Canada Insurance Services Inc. The initial deposit (cheque) should be forwarded with the Master Application. The deposit is equal to one month s premium. Subsequent invoices will be billed as of the fifth day of the month prior to the month due. For example, a September 5th invoice is due and payable on October1st. Payments should be made by Electronic Funds Transfer (EFT), unless an arrangement has been made to pay by cheque. A grace period of thirty days applies, subsequent to which, the plan will be cancelled. On behalf of (Entity/Company), I confirm that the statements made in this application are true and correct. I understand and agree that any misrepresentation, omissions, concealment of acts and incorrect statements may prevent a recovery under the policy, void or rescind coverage, or alter rates at inception, if such statements are fraudulent, or are material either to the acceptance of the risk or to the hazard assumed by the insurer, or if the insurer in good faith having relied on such statements would either not have issued the policy, or would not have provided coverage if the true facts had been made known to the insurer. I apply for Global Medical Care coverage effective Date (mm/dd/yy) Signature Print Name Title Witness Signature Print Name Date (mm/dd/yy) For the purposes of the Insurance Companies Act (Canada), this policy was issued in the course of Lloyd's Underwriters' insurance business in Canada. Best Doctors Insurances arranged at Lloyd s. Best Doctors Canada Insurance Services Lloyd s Coverholder. Underwritten by certain underwriters at Lloyd s. Best Doctors, the Star-In-Cross logo, InterConsultation, Elite Navigator, Best Doctors Member Care Network and Best Doctors Global Medical Care are trademarks or registered trademarks of Best Doctors, Inc. in the United States of America, Canada, and in other nations, and licensed under agreement to Best Doctors Canada Insurance Services Inc. Complete definitions and limitations are found in the Master Policy. Underwritten by certain underwriters at Lloyd's.