CDSPI Undergraduate Package (under 40) / Assurance des étudiants de premier cycle (moins de 40 ans)

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No-Cost Undergraduate Package Enrolment Form for Students
Under Age 40
Life, Accidental Death & Dismemberment (AD&D), Disability and TripleGuard™ Insurance

Life, AD&D, and Disability insurance are underwritten by The Manufacturers Life Insurance Company (Manulife). TripleGuard™ insurance is underwritten by Aviva Insurance Company of Canada.
Thank you for your interest in the CDSPI No-Cost Undergraduate Insurance Package. Let’s start by determining which application to complete.

a) If you are a permanent resident of Quebec, apply here using the fillable PDF.

b) If you are a permanent resident of any other province in Canada, please proceed with the online application below.
Are you eligible?

You are eligible for coverage if you are a dental Student. "Student" means a full time dental student enrolled in an accredited Canadian school or faculty of dentistry who is a Canadian citizen or a permanent resident of Canada.
Are you a full-time dental student? *

Yes No
Are you a Canadian citizen or permanent resident of Canada? *

Yes No

It looks like you are not eligible for our No-Cost Undergraduate Insurance Package

To be eligible for this offer you must be a full-time dental student enrolled in an accredited Canadian school or faculty of dentistry. You must also be a Canadian citizen or a permanent resident of Canada.

Looking for tips and tools on how to tackle debt and saving? We invite you to explore our Insights Hub for the latest articles, podcasts and videos on a variety of topics geared to students.

University Information
University: *
Year of graduation: *
Are you enrolled in the qualifying program for foreign-trained dentists?

Yes No

Contact Information
Current mailing address: *

Street and Number

Suite No.

City/Town
Province *
Province
Postal Code *
Postal Code
Cellular Telephone: *
Cell phone
Other Telephone:
Other phone
Email Address *
email
QUEBEC RESIDENTS:

Thank you for your interest in the CDSPI No-Cost Undergraduate Insurance Package. You can download and complete the fillable PDF Insurance enrolment forms in the student section of our forms page at https://www.cdspi.com/forms/

If you have any questions, please contact us at at: 1.800.561.9401 or insurance@cdspi.com.

Secondary Contact Information

e.g. permanent home address (optional)
Other fixed address:

Street and Number

Suite No.

City/Town
Province
Province
Postal Code
Telephone
other telephone
QUEBEC PARTICIPANTS ONLY

Thank you for your interest in the CDSPI No-Cost Undergraduate Insurance Package. You can download the fillable PDF Insurance enrolment forms from the student offer page of the CDSPI Website: https://www.cdspi.com/student-offer/

If you have any questions, please contact us at at: 1.800.561.9401 or insurance@cdspi.com

www.cdspi.com

Beneficiary Information
Your beneficiary designation is revocable* unless you specify otherwise. If you wish to make your beneficiary irrevocable, please contact CDSPI to obtain a form for this purpose.
I designate the person named below as my beneficiary to receive any money payable under the Life and AD&D Insurance upon my death (First,Middle,Last). *

First Name Middle or Initial Last Name
designated beneficiary (Last, First (Middle)): {iDesignate:last}, {iDesignate:first} ({iDesignate:middle})
Beneficiary's relationship: *
Beneficiary's relationship to the person to be Insured
Note: The person insured cannot also be the beneficiary. Please name another person as your benficiary and remove the word self from the beneficiary's relationship.
If you need to add a second beneficiary, or if this beneficiary is a minor, please contact us at 1.800.561.9401 or insurance@cdspi.com.

If you designate a beneficiary who is a minor when benefits become payable, benefits will be paid into court or to the Public Trustee, unless a trustee is appointed. By appointing a trustee below, you agree that if the beneficiary is a minor on the date that benefits become payable, the benefits will be paid to the trustee to hold in trust for the minor until the minor comes of age.

Important Notes:
- You must be age 18 to 39 on the date this Enrolment Form is received by CDSPI and meet other eligibility criteria to receive coverage. If you are age 40 to 64, you must complete a different form. Contact CDSPI for details.
- No medical underwriting is required for students who are age 18 to 39.
- The “Double-Up” Graduate Package is provided automatically upon graduation. The “Double-Up” Graduate Package has twice the life, LTD and AD&D protection — and you pay absolutely no premiums for this coverage up to December 31st of your graduation year.
- Effective January 1st after your graduation year, you will save 50 per cent on regular premiums for the Life, AD&D and TripleGuard™* Insurance in the “Double-Up” Graduate Package for three calendar years following graduation and enjoy a 15% lifetime savings on regular premium rates for DisabilityGuard™ Insurance plan for the life of the policy. DisabilityGuard™ premium rates are guaranteed to age 65.
*TripleGuard™ insurance is underwritten by Aviva Insurance Company of Canada.

Accessible formats and communication supports are available upon request. Visit www.cdspi.com/accessibility for more.

LIFE, AD&D AND DISABILITYGUARD™ INSURANCE ARE UNDERWRITTEN BY THE MANUFACTURERS LIFE INSURANCE COMPANY (MANULIFE).

Manulife has the authority to grant or refuse insurance coverage based on health considerations. Precise details, terms, conditions and exclusions are set out in the insurance contracts for these plans. Manulife, Manulife & Stylized M Design, and Stylized M Design are trademarks of The Manufacturers Life Insurance Company and are used by it, and by its affiliates under license © 2020 The Manufacturers Life Insurance Company. All rights reserved. Manulife, P.O. Box 670, Waterloo Stn, Waterloo, ON N2J 4B8

Declaration and Authorization

(To be read and signed by Applicant/Person To Be Insured.)

Notice on Exchange of Information - must be read
NOTICE ON EXCHANGE OF INFORMATION — MUST BE READ AND RETAINED BY THE PERSON TO BE INSURED.

All information requested will be for insurance purposes only and will be treated as confidential. The insurer or its reinsurers may, however, make a brief report on it to the MIB Group, Inc. (MIB MIB is a non-profit membership organization of life insurance companies which operates an insurance information exchange on behalf of its members. Subject to your authorization, MIB will supply information from its files to another member insurance company to which you have applied for life or health insurance or to which a claim is submitted. On your request, MIB will arrange for disclosure to you of any information it may have in your file. If you question the accuracy of MIB’s file, you may contact MIB and seek a correction. You can reach the MIB’s information office by writing to 330 University Avenue, Suite 501, Toronto, ON M5G 1R7, calling 416.597.0590 or emailing canada_disclosure@mib.com.

Privacy & Confidentiality - must be read
MUST BE READ BY THE PERSON TO BE INSURED.

Manulife’s Notice on Privacy and Confidentiality:

In this Statement, “you” and “your” refer to the policyowner or holder of rights under the contract, the insured providing consent. “We”, “us”, “our” and “the Company” refer to The Manufacturers Life Insurance Company and our affiliated companies and subsidiaries.

Updates to this Statement and further information about our privacy practices are posted to www.manulife.ca.

We collect, use, verify and disclose your personal information for identified purposes, and only with your consent, or as permitted or required by law. By selecting submit or by signing the application, you give your consent for us to collect, use and disclose your personal information, as set out in this Personal Information Statement. Any alterations to the consent must be agreed to in writing by the Company.

What personal information do we collect?

Depending on the product you have applied for, we collect specific personal information about you, such as:
- Identifying information such as your name, address, telephone number(s), email address, date of birth, or driver’s licence
- A personal investigation, financial information, credit bureau report and/or a consumer report from any other organization, person or source that has any information or records about you
- Information about how you use our products and services, and information about your preferences, demographics and interests
- Other personal information we may require to administer our business relationship with you
- We use fair and lawful means to collect your personal information.
Where do we collect your personal information from?
- Your completed applications and forms
- Other interactions between you and the Company
- Other sources, such as:
  - Your advisor or authorized representative(s)
  - Third parties with whom we deal in issuing and administering your policy now, and in the future
  - Public sources, such as government agencies and internet sites
What do we use your personal information for?

We will use your personal information to:
- Help us properly administer the products and services that we provide and to manage our relationship with you
- Confirm your identity and the accuracy of the information you provide
- Evaluate your application, and issue and administer the rights under the policy
- Comply with legal and regulatory requirements
- Understand more about you and how you like to do business with us
- Analyze data to help us understand our customers better so we can improve the products and services we provide
- Determine your eligibility for, and provide you with details of, other products or services that may be of interest to you
Who do we disclose your information to?
- Persons, financial institutions and other parties with whom we deal in issuing and administering your policy now, and in the future
- Authorized employees, agents and representatives
- Any person or organization to whom you gave consent
- People who are legally authorized to view your personal information
- Service providers who require this information to perform their services for us (for example data processing, programming, data storage, market research, printing and distribution services, paramedical and investigative agencies)
- Your medical doctor
- Public health authorities as required, if laboratory tests performed on our behalf show that you have tested positive for infectious disease
The abovementioned people, organizations and service providers are both within Canada and jurisdictions outside Canada, and would therefore be subject to the laws of those jurisdictions.

Where personal information is provided to our service providers, we require them to protect the information in a manner that is consistent with our privacy policies and practices.

The personal information you provided in this application:
- will become a part of all the contracts that result from this application, even if you are not the owner or one of the people to be insured for that printed contract
- will be shared with all the owners and any subsequent owners of those contracts and all people to be insured
How long do we keep your information?

The longer of:
- the time period required by law and by guidelines set for the financial services industry, and
- the time period required to administer the products and services we provide.
Withdrawing your consent

You may withdraw your consent for us to use your personal information to provide you with other service or product offerings, excluding those mailed with your statements.

You may not withdraw your consent for us to collect, use, retain or disclose personal information we need to issue or administer the policy unless federal or provincial laws give you this right. If you do so, a policy may not be issued and benefits will not be payable under the contract or we may treat your withdrawal of consent as a request to terminate the contract.

If you wish to withdraw your consent, phone our customer care centre at 1-877-261-8222, or write to the Privacy Officer at the address below.

Accuracy and Access

You will notify us of any change to your contact information. You have the right to access and verify your personal information maintained in our files, and to request any factually inaccurate personal information be corrected, if appropriate. If you have a question or a concern, wish to receive more information about parties who have access to your information or about our privacy policies and procedures, and/or wish to review your personal information in our files or correct any inaccuracies, you may send a written request to:

Privacy Officer

Manulife

P.O. Box 1602

500 King Street North

Waterloo, ON N2J 4C6

Privacy_office_canadian_division@manulife.com

Please note the security of email communication cannot be guaranteed. Do not send us information of a private or confidential nature by email. By contacting us via email you are authorizing us to communicate with you by email.

Aviva’s Privacy Notice: Aviva Insurance Company of Canada is committed to protecting your personal information and using or disclosing it only for the purposes for which it is collected. For more information about how Aviva uses and protects your personal information, please refer to Aviva’s privacy statement at www.avivacanada.com. You may request to review and make corrections to the personal information in the insurer’s file by writing to

Aviva Canada Inc.

Attention: Privacy Officer

10 Aviva Way, Suite 100

Markham, Ontario

L6G 0G1

or sending an email to CAPrivacyOfficer@avivacanada.com

CDSPI’s Privacy Notice: CDSPI and CDSPI Advisory Services Inc. collect, use and disclose your personal information on this application for purposes that include: determining your eligibility for our plans; administering and providing insurance and financial services to you; underwriting; claims adjudication; protecting against fraud, errors or misrepresentations; meeting legal, regulatory or contractual requirements; marketing and to advise you of other related products and services. We limit access to your personal information in our files to our employees, authorized agents and third- party service providers, and to any other person you authorize or as authorized by law. These people, organizations and service providers may be in countries outside Canada, so your personal information may be subject to the laws of those countries. You may request to review the personal information your file contains and make corrections by sending a written request to:

CDSPI, Attn: The Chief Privacy Officer

2005 Sheppard Ave East, Suite 500

Toronto, ON

M2J 5B4

To find out more about our privacy practices, visit www.cdspi.com/privacy.

Accessible formats and communication supports are available upon request. Visit www.cdspi.com for more information.

Authorization
I have read and agree to the privacy & confidentiality statements *

I have read and agree to the privacy & confidentiality statements
I apply to The Manufacturers Life Insurance Company (Manulife) for insurance under the group policies, Life, Accidental Death & Dismemberment, and Disability, and to Aviva Insurance Company of Canada for TripleGuard™ insurance, issued in connection with CDSPI.

I acknowledge receipt of and confirm my agreement with Manulife's Notice on Privacy and Confidentiality, Aviva's Privacy Notice and CDSPI's Privacy Notice.

I, the undersigned, declare that the statements contained in this form are true and complete and, together with any other forms that may be signed by me in connection with this application, form the basis for any policy or certificate issued under the group policies.

I understand that any material misrepresentation, including misstatement of smoker status, shall render any insurance issued pursuant to this application voidable at the instance of the insurer.

I understand that for life insurance, death resulting from suicide within 2 years of the effective date or any reinstatement date is not covered.

I understand that conditions, limitations and exclusions apply to the insurance products applied for in connection with this application.

Important: In respect of the Undergraduate Package and “Double-Up” Graduate Package: This Form must be received by CDSPI by your graduation date and within 30 days of the signature date below, in order to enrol in the Undergraduate Package and the “Double-Up” Graduate Package. I understand that, provided that I am under age 40 when I apply, I do not need to provide evidence of good health to apply for the Undergraduate Package and “Double-Up” Graduate Package. However, a pre-existing condition exclusion will be applicable to Life and Disability coverage that is not medically underwritten. Claims arising from a pre-existing condition, which means an illness or condition for which treatment or advice was or should have been sought during the 12 month period prior to the effective date of coverage, are excluded. This exclusion will not apply to any claim arising after coverage has been in effect for 12 months.

A photocopy or facsimile of this authorization shall be as valid as the original.
Signed at City/Town *
City/Town
Province *
Province
Date *

Day Month Year
DD-MM-YYYY
Signature for PDF
After clicking Sign with DocuSign below, you will be redirected to an external DocuSign website where you will have the opportunity to review the application and provide your eSignature. Once you eSign the application, it will be automatically submitted to CDSPI and a copy will be emailed to the email address provided for your records. *
Online Form Feedback: Click Here To Report Form Issues or Submit Questions
Should be Empty:

Are you eligible?

Applicant Information

University Information

Contact Information

Secondary Contact Information

Beneficiary Information

Declaration and Authorization