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  • DisabilityGuard™ Insurance/ Office Overhead Expense Insurance

  • Thank you for your interest in CDSPI's DisabilityGuard™ Insurance. Let's start by determining which application to complete.

    1. If you are a permanent resident of Quebec, apply here using the fillable PDF.
    2. If you are a permanent resident of any other province in Canada, please proceed with the online application below.

    Information you will need to complete this application:

    • Personal information
    • Your doctor's name, address and telephone number
    • Information about your medical history

    You may want to have the following documents available:

    • Financial documentation to confirm your income (T1 General - Income Tax and Benefit Return and/or Corporate Financial Statements as applicable) or your accountant's contact information.
    • Information related to any pending or existing Disability Insurance held with other companies.
  • For assistance in filling out this application, please call: CDSPI Advisory Services Inc. 1.800.561.9401 or 416.296.9401, E-mail: insurance@cdspi.com

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

    CDSPI, 2005 Sheppard Ave East, Suite 500, Toronto, ON, M2J 5B4

  • DisabilityGuard™ Insurance Application

  • This online application form is ony available to be filled in by the person who is being insured:

    Thank you for your interest in the CDSPI DisabilityGuard™ Insurance & Office Overhead Expense Insurance Plan. This online application form is only available when the dentist who is being insured does not need a second person to sign as the applicant. For applications where two signatures are required, please download and complete the fillable PDF insurance application form and return it to our office at:
    CDSPI, 2005 Sheppard Ave East, Suite 500, Toronto, ON M2J 5B4
    Fax: 1.866.337.3389 or 416.296.89200

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

     

  • Applicant Information

  • Name of Applicant:

     
  • QUEBEC Residents:

    Thank you for your interest in the CDSPI DisabilityGuard™ Insurance & Office Overhead Expense Insurance Application. The online application form is not available to you at this time, but you can download and complete the fillable PDF insurance application form and return it to our office at:
    CDSPI
    2005 Sheppard Ave East, Suite 500,
    Toronto, ON M2J 5B4
    Fax: 1.866.337.3389 or 416.296.89200

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

     

  • Person To Be Insured

    Please complete even if the person to be insured is the same as the applicant
  • Name Of Person To Be Insured:

     
  • Note: You are considered a non-smoker if you have not used any form of tobacco, tobacco cessation products or e-cigarettes in the 12 months prior to signing this application. Note, however, that you must be approved by the insurer for non-smoker rates and that such approval is dependent on your smoking status and overall health history.

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  • Confirm Status:

     
  • Membership Required:

    Thank you for your interest in the CDSPI DisabilityGuard™ Insurance & Office Overhead Expense Insurance Plan. You must be a member of the CDA or of a Provincial or Territorial Dental Association (excluding the ACDQ in Quebec) to apply. To learn more about CDA membership, click here

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

     

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  • Note: You are considered a non-smoker if you have not used any form of tobacco, tobacco cessation products or e-cigarettes in the 12 months prior to signing this application. Note, however, that you must be approved by the insurer for non-smoker rates and that such approval is dependent on your smoking status and overall health history. 

     

  • COVERAGE APPLIED FOR

  • DisabilityGuard™ Insurance

     
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  • Note: When you fill out the monthly income benefit you want in this question, do not include any existing disability coverage you may have. For example, if you currently have $3,000 of disability insurance and are applying for an additional $1,500 of coverage, indicate $1,500 only in the areas above which indicate the amounts applied for. Do not enter the total amount of coverage you will have after your application has been approved.

  • NOTE: Only available at time of initial application for the DisabilityGuard™ Insurance plan. See the DisabilityGuard™ Insurance plan sheet for details.

  • DECLARATION OF INSURABILITY

  • IMPORTANT: Any reference to testing, tests, test results, or investigations in this section excludes genetic tests.*

    *Genetic tests means a test that analyzes DNA, RNA, or chromosomes for purposes such as the prediction of disease or vertical transmission risks, or monitoring, diagnosis, or prognosis.

  • TO BE COMPLETED BY THE PERSON TO BE INSURED

    YOUR PERSONAL INFORMATION
  • DECLARATION OF INSURABILITY (continued)

  • YOUR FAMILY MEDICAL HISTORY

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  • YOUR MEDICAL INFORMATION

    Have you ever had any indication of or been treated for conditions involving any of the following:
  • DisabilityGuard/Office Overhead Expense Insurance Cont'd

  • During the past 5 years, have you:

  • Have you:

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  • Within the past 2 years, have you:

  • Financial Information of Person To Be Insured

  • Annual Earned Income consists of income earned by you in any and all occupations and/or from any business or professional practice (excluding unearned or investment income such as pensions, interest, dividends, etc.) after deducting business expenses, but before income taxes.

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  • Note: Every field must be filled with a number only.

  • Please provide amount of your unearned income for:

  • PROOF OF INCOME: Applicable to DisabilityGuard™ Insurance

    If your total coverage from all sources will exceed $4,000/month, please provide a copy of your last personal income tax return (a Notice of Assessment is not acceptable). If incorporated, also provide a copy of your last Corporate Financial Statement (all pages). If you are purchasing an existing practice, also provide a copy of the last Financial Statement (all pages) from the practice you are purchasing.

    NOTE: If you are a dental specialist in your first 2 years of practice after graduating from a specialty program, no proof of income is required for up to $7,500/month total from all sources* for disability coverage.

    *Total all sources = All existing and applied for coverage with all companies

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  • Other Insurance

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  • NOTE: If you intend to replace coverage, do not cancel your existing coverage until you receive your new insurance contract. In Quebec, a replacement form or declaration may be required, and we may not be able to issue an insurance contract where replacement is indicated.

  • Office Overhead Expense(OOE) Insurance

  • If you suffer a disabling injury or illness, Long Term Disability Insurance will help protect your income. But that is only part of the picture, since you will still have to contend with the ongoing expenses of your pracitce.

    That's where Office Overhead Expense Insurance helps out. The plan pays the eligible office expenses you actually incur - up to your monthly coverage amount - if illness or injury prevents you from working.

     

    Gain these advantages

    • Monthly benefits to cover expenses such as rent, utilites and staff salaries
    • Special features such as survivor and maternity leave benefits
    • Options to tailor the plan for your needs
    • Attractive premiums - including lower  HealthEdge rates
  • Office Overhead Expense (OOE) Insurance

    The completion of this section will help calculate the amount of Office Overhead Expense coverage you require for your portion of expenses. Only expenses relating to dental pracitces are insurable.
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  • * Do not include salary paid to yourself or any member of your profession or any income splitting with a family member.

  • *Total coverge in force and applied for may not exceed this amount.

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  • Note: Own Occupation and Future Insurance Guarantee Options are avilable for an additional premium. See the Office Overhead Expense insurance plan sheet for details. 

     

  • PROOF OF EXPENSES: Applicable to Office Overhead Expense (OOE) Insurance

    If your total* OOE coverage will exceed $4,000/month, please provide a copy of your last income and expense statement. The statement should be prepared by an accountant and reflect at least 6 months of income and expenses. If you are purchasing an existing practice, also provide a copy of the last Financial Statement (all pages) from the practice you are purchasing.

    NOTE: If you are a dental specialist in your first 2 years of practice after graduating from a specialty program, no proof of expenses is required for up to $7,500/month total from all sources* for OOE coverage.

    * Total all sources = All existing and applied for coverage with all companies.

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    • PAYMENT INFORMATION  
    • *A 2.23% processing charge applies to monthly and quarterly payments

    • NOTICE ON EXCHANGE OF INFORMATION  
    • Information regarding your insurability will be treated as confidential. Manulife or its reinsurers may, however, make a brief report on it to MIB, Inc., formerly known as the Medical Information Bureau, a non-profit membership organization of insurance companies which operates an insurance information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information about you in its file. Manulife or its reinsurers may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Upon receipt of a request from you, MIB will arrange disclosure of any information in your file. Please contact MIB at (416) 597-0590. If you question the accuracy of the information in MIB’s file, you may contact MIB and seek a correction. The address of MIB’s information office is: 330 University Avenue, Suite 501, Toronto, Ontario M5G 1R7. Information for consumers about MIB may be obtained on its web site at www.mib.com.

    • NOTICE ON PRIVACY AND CONFIDENTIALITY  
    • 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 and the parent or guardian of any child named as insured who is under the legal age for 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, your date of birth, or driver’s license Medical information that any organization or person has about you
      • Any test that may be necessary for us to decide if and on what terms to insure you, such as a medical exam or blood test.
      • Your personal information from MIB, Inc., as explained in Information about MIB, Inc.
      • A copy of all driving related information from provincial or territorial Motor Vehicle Divisions
      • A personal investigation, financial information, credit bureau report and/or a consumer report from other organizations, 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, recorded Teleinterviews 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.

      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.

    • CONFIRMATION OF NOTICE ON PRIVACY AND CONFIDENTIALITY  
  • DECLARATION AND AUTHORIZATION

  • To Be Read, Signed and Dated By the Applicant (and Person To Be Insured If Other than the Applicant)

  • If this application is approved, the applicant will receive a certificate booklet containing a detailed description of coverage and limitations.

    I apply to The Manufacturers Life Insurance Company (Manulife) for the insurance indicated above under the group policies issued in connection with CDSPI.

    I/We, the undersigned, declare that the statements contained in this application, including the statements in the Declaration of Insurability, are true and complete, and together with any other forms or documents signed or provided by me/us in connection with this application, form the basis for any Certificate of Insurance issued. I/We understand that any material misrepresentation at the time of application, including misstatement of smoker status, shall render the insurance voidable at the instance of the insurer. I/We understand that the insurance will take effect on the date the properly completed application is approved by Manulife, subject to the person to be insured being actively at work on that date and to payment of the first premium within 30 days of issuance of a premium invoice. I/We understand that any health information must be accurate as of the date the application is signed.

    I/We acknowledge receipt of and confirm my/our agreement with the Notice on Privacy and Confidentiality and the Notice on Exchange of Information.

    Relative to the insurance applied for, I, the Person To Be Insured, authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medically related facility, insurance company, MIB Group, Inc., the group policy administrator, the insurance plan sponsor, any investigative and security agency, any agent, broker or market intermediary, any government agency or other organization or person (including my accountant) that has any records or knowledge of me, my health or my finances to provide to Manulife or its reinsurers any such information for the purposes of this application and contract and any subsequent claim. I/We authorize Manulife to consult its existing files for this purpose. I/We declare that I/we have been made aware of the reasons why the health information is needed and the risks and benefits to the individual of consenting or refusing to consent. I/We understand that consent may be revoked at any time and that, if as a result of such revocation the insurer is unable to obtain proof of claim, this may result in claims not being paid. A photocopy or facsimile of this authorization shall be as valid as the original.

    NOTE: Eligibility for coverage or increased coverage is limited to Canadian citizens or permanent residents of Canada who are members of the CDA or participating provincial or territorial dental associations (in Quebec, only CDA members are eligible).

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