Application for Insurance - PHS SELECT Programs

Please submit this Application and the Personal Health Declaration with a cheque marked "VOID". For more information or assistance in completing this application, or to request additional applications & health statements, please contact the Program Administrator at 604-606-3388 or visit our website at http://www.paragonhealthsolutions.com

Section 1: General Information

LAST NAME:

FIRST NAME:

 INITIAL:

 MARITAL STATUS:

Married Single Common-Law
Other

DATE OF BIRTH (DD/MM/YYYY)

SEX
M F		 LANGUAGE

 Primary Occupation
HOME ADDRESS

CITY

 PROVINCE

 POSTAL CODE

HOME TELEPHONE

WORK TELEPHONE

FAX
EMAIL ADDRESS

EMPLOYMENT STATUS

YOUR COMPANY NAME

BUSINESS ADDRESS

CITY

 PROVINCE

 POSTAL CODE

YOUR AGENT/BROKER NAME (If Applicable)

 YOUR AGENT/BROKER TELEPHONE

YOUR AGENT/BROKER EMAIL ADDRESS

YOUR AGENT/BROKER ADDRESS

 CITY

 PROVINCE

 POSTAL CODE
       

Section 2: Coverage Selection & Plan Choice

1. Please indicate your level of coverage:

Single

Couple

Two Parent Family with

Single Parent Family with

Children


2. Please choose your plan:

EHC ONLY EHC + DENTAL

Basic Basic Plus SELECT

Section 3: Dependent Information

  Last Name First Name & Initial Sex (M or F) Birthdate (DD/MM/YYYY) If child is over 21
Spouse: M F STUDENT DISABLED
Child: M F STUDENT DISABLED
Child: M F STUDENT DISABLED
Child: M F STUDENT DISABLED
Child: M F STUDENT DISABLED
If a Child is over age 21, state if a Student or Disabled. Students must provide proof of attendance at school (ie. a copy of their student card).
If your Spouse is currently insured under another Health Care benefit plan, please provide the following information
SPOUSE'S EMPLOYER (OR NAME OF THE OTHER PLAN)

 OTHER HEALTH CARE PLAN POLICY NUMBER

 INSURANCE COMPANY NAME

Section 4: Privacy & Confidentiality

We protect our customers' confidential information. A combination of industry, legislated and our own corporate privacy and confidentiality requirements govern the level of detail shared about any plan member and his or her dependents' benefits. In terms of telephone inquiries to Alternative Benefit Solutions Customer Service, the information provided varies based on the relationship of the person making the inquiry to the insured (e. g. plan administrator, plan member or dependent). After the caller has been screened for appropriate identification, only information pertaining to the specific claim or treatment in question.

Notes:

  • All levels of coverage require you to complete the attached Personal Health Declaration in order to be approved for coverage. You may also choose to enhance your coverage with one of the four Optional Benefits mentioned above. If so, please complete the separate PHS Income Protection Program application form.
  • Coverage commences only after the Plan Administrator confirms your acceptance in writing. Coverage may be amended or surcharged based on the information provided in the Personal Health Declaration and any pre-existing conditions
  • Please remember to attach a cheque marked "VOID" to enable monthly premium payments.

World Insurance Services
201 - 7080 River Road
Richmond BC V6X 1X5

 

 

 Tel: 604-606-3388
Fax: 604-606-3399
Toll Free: 1-866-809-6753
e-Mail:

Section 5: Optional Benefits

Optional Benefits can be selected to enhance your overall protection or address specific personal needs. A separate application form is required and can be found in the following pages. However, please indicate here which Optional Benefits you will be applying for:

Temporary Total Disability Benefits: Requires separate Application Form. Please complete the Income Protection Program Application that follows.
Permanent Total Disability Benefits: Requires separate Application Form. Please complete the Income Protection Program Application that follows.
Critical Illness Benefit: Requires separate Application Form. Please complete the Income Protection Program Application AND ACE INA Health Statement
Accidental Death & Dismemberment: Requires separate Application Form. Please complete the Income Protection Program Application that follows.

Section 6: Calculate your Monthly Cost: (not including Optional Benefits)

Enter the amount from our web site corresponding to the plan you desire . The cost of any Optional Benefits you have selected will be added to this amount, and the total amount will be withdrawn from your financial institution each month. Please attach a cheque marked "VOID" to enable these monthly withdrawal

 Your Total
Monthly
Benefits Cost $

Section 7: Declaration & Authorization

We protect our customers’ confidential information. A combination of industry, legislated and our own corporate privacy and confidentiality requirements govern the level of detail shared about any plan member and his or her dependents’ benefits. In terms of telephone inquiries to World Insurance Services , the information provided varies based on the relationship of the person making the inquiry to the insured (e. g. plan administrator, plan member or dependent). After the caller has been screened for appropriate identification, only information pertaining to the specific claim or treatment in question is shared.