CDSPI DisabilityGuard™ Application Form / Assurance SolutionInvalidité(MC)

{ApplicantLastFirstMiddle} {uniqueid}
AdvisorCode
MarketingCode
Date and Time Form was Started:

Year Month Day
Date
Hour Minutes
CDSPI Administrative Email
example@example.com
UniqueID
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
I am applying on behalf of: *

Myself Another Dentist A Corporation
Is the person to be insured the same as the signing officer of the corporation? *

Yes No
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
Applicant: *

Dentist Corporation
Name of Applicant:
Applicant
Applicant Last, First (Middle)
Name of Partnership or Corporation: *
Dr
First Name *
Middle Name
Or Middle Initial
Last Name *
Sex: *

Male Female
Type of Mailing Address: *

Home Business
Mailing Address: *

Street and Number

Suite No.

City / Town
Province: *
Postal Code: *
Postal Code
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.
Business Telephone: *
Home Telephone:
Mobile Telephone: *
Fax:
E-mail address: *
CDSPI Account Number, if known:
Language Preference: *

English French

	Elimination Period	Monthly Benefit $	Premium Type
'

YOUR FAMILY MEDICAL HISTORY
Have any of your parents or siblings been diagnosed prior to age 60 with heart disease, stroke or cancer? *

Yes No
Have any of your parents or siblings been diagnosed with Huntington's chorea, polycystic kidney disease or other kidney disease (excluding kidney stones), Parkinson's disease, multiple sclerosis, Alzheimer's disease, amyotrophic lateral sclerosis (also called ALS or Lou Gehrig's disease) or other motor neuron disease, diabetes, hepatitis, or retinitis pigmentosa? *

Yes No

Other Insurance
Do you currently have in force or have you concurrently applied for any sickness or accident coverage (including disability coverage through your employer), Office Overhead Expense or Retirement Protection coverage, provided by Individual or Group Policies, or Employment Contracts/Partnership Agreements, other than through CDSPI? *

Yes No

	Insuring Company or Plan	Amount of Monthly Benefit ($)	Type of Coverage	Elimination Period	Benefit Period (e.g. 5 yrs., to age 65, etc.)	Taxable Benefit?	Are you replacing this coverage?

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
Would you be interested in Office Overhead Expense Insurance? *

Yes No

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.

Average Monthly Expenses for Professional Practices (your portion) *

	Amount (in increments of $100)
Accounting Services
Interest on Loans, Depreciation/Rental
Association Membership Dues
Rent/Mortgage Interest Payments
Employee Salaries and Benefits*
Telephone, Internet Service, Answering Service, Pager
Utilites (Electricity, Heat, Laundry, Office Maintenance)
Other customary and reasonable fixed expenses incurred
Business insurance premiums

* Do not include salary paid to yourself or any member of your profession or any income splitting with a family member.
Please list other expenses:
Your Portion of Total Average Monthly Overhead Expenses*
*Total coverge in force and applied for may not exceed this amount.
Number of employees: *
Full-time
*
Part-time

Amount of insurance applied for (not including existing coverages) in increments of $100: *

	Elimination Period	$ (in increments of $100)	Payment Option	Benefit Period	Future Insurance Guarantee	Own Occupation
1
2

I would like to add the following options to my existing Office Overhead Expense coverage:

Future Insurance Guarantee Own Occupation
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.
You can upload your proof of expenses to our secure site. *

I will upload the proof of expenses with this application. My total Office Overhead Expense coverage from all sources will not exceed $4,000 per month (or $7,500 for specialists within first two years of practice).
Please upload proof of your expenses here:

Please upload your last income and expense statement and, if purchasing an existing practice also provide a financial statement (if not already supplied)
Cancel of

PAYMENT INFORMATION
Payment Method (Choose One): *

Invoice (Will be mailed to your address on file for payment.) Automatic Payments
Automatic Payment

Pre-authorized Chequing Plan (PAC) - Please complete the Pre-Authorized Chequing Plan Form which will be sent via email after we receive your application. Visa / Mastercard - CDSPI will contact you to obtain credit card details upon receipt of your application
Payment Frequency (Choose One): *

Same as current (Only applies if you are an existing client paying premiums) Annual Quarterly* Monthly* (You must select Automatic Payments under the Payment Method section above)
*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
Please click the headings above to expand and read full notice: *

I have read and agree to the Notice on Exchange of Information and the Privacy & Confidentiality statements.

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).
Signed At:

Street Address

Street Address Line 2

City / Town Province / Territory
Signed on Date: *

Day Month Year
Date
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:

	Family Member	Condition (if cancer, specify type)	Age at Onset	Age at Death (if applicable) and Cause

	Current Year to Date	Last Year End	Year End - Two Years Prior
Your gross earned income (from all sources) including salary, fees, commissions and bonuses:
Less annual total of all your business expenses:
Net annual earned income after expenses and before taxes:

DisabilityGuard™ Insurance/ Office Overhead Expense Insurance

DisabilityGuard™ Insurance Application

Applicant Information

Person To Be Insured

COVERAGE APPLIED FOR

DECLARATION OF INSURABILITY

TO BE COMPLETED BY THE PERSON TO BE INSURED

DECLARATION OF INSURABILITY (continued)

YOUR FAMILY MEDICAL HISTORY

YOUR MEDICAL INFORMATION

DisabilityGuard/Office Overhead Expense Insurance Cont'd

During the past 5 years, have you:

Have you:

Within the past 2 years, have you:

Financial Information of Person To Be Insured

Other Insurance

Office Overhead Expense(OOE) Insurance

Office Overhead Expense (OOE) Insurance

DECLARATION AND AUTHORIZATION

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