ENROLLMENT OR RE-ENROLLMENT APPLICATION FOR LIFE, DISABILITY, HEALTH, DENTAL AND TRAVEL BENEFITS CANADA LIFE POLICY

Family Name			First Name			Middle Initial	PGYLevel
Address (Number, Street, APT. Number)			Email		City	Province	Postal Code
Date of Birth	Gender Male Female	Marital Status Single Married Common-Law		Province of Employment	Program Start Date	Student ID#

2. Applying For Coverage:

Health	Dental
		Myself only Myself and dependants None because my partner has coverage
IF DEPENDENTCHILD OVER AGE 21 IS A FULL-TIME STUDENT OR DISABLED, PLEASE COMPLETE CANADA LIFE FORMGL0514E AVAILABLE FROM THE MARITIME RESIDENT DOCTORS OFFICE.

4. Privacy Information:

AT MARITIME RESIDENT DOCTORS,WE RECOGNIZE AND RESPECT THE IMPORTANCE OF PRIVACY. WHEN YOU APPLY FOR COVERAGE, WE ESTABLISH A CONFIDENTIAL FILE THAT IS KEPT IN THE OFFICE OF MARITIME RESIDENT DOCTORS.WE LIMIT ACCESS TO PERSONAL INFORMATION IN YOUR FILE TO THE INSURERS/CLAIMS PAYERS OR PERSONS AUTHORIZED BY MARITIME RESIDENT DOCTORS WHO REQUIRE IT TO PERFORM THEIR DUTIES, TO PERSON TO WHOM YOU HAVE GRANTED ACCESS, AND TO PERSONS AUTHORIZED BY LAW. WE USE THE PERSONAL INFORMATION TO DETERMINE YOUR ELIGIBILITY FOR COVERAGE AND TOADMINISTER THE GROUP BENEFITS PLAN.

I HEREBY APPLY FOR COVERAGE UNDER THE GROUP BENEFITS PLAN ISSUED BY INSURERS/CLAIMS PAYERS. I AUTHORIZE THE INSURERS/CLAIMS PAYERS, ANY HEALTHCARE PROVIDER, MY PLAN ADMINISTRATOR, OTHER INSURANCE OR REINSURANCE COMPANIES ADMINISTRATORS OF GOVERNMENT BENEFITS OR OTHER BENEFITS PROGRAMS, OTHER ORGANIZATIONS, OR SERVICE PROVIDERS WORKING WITH MARITIME RESIDENT DOCTORS TO EXCHANGE PERSONAL INFORMATION, WHEN NECESSARY TO DETERMINE MY ELIGIBILITY FOR COVERAGE AND TO ADMINISTER THE PLAN. IF APPLYING FOR COVERAGE FOR MY PARTNER AND/OR DEPENDENTS, I CONFIRM THAT I AM AUTHORIZED TO ACT ON THEIR BEHALF. I AGREE THAT A PHOTOCOPY OR ELECTRONIC COPY OF THIS AUTHORIZATIONS AND DECLARATIONS SECTION IS AS VALID AS THE ORIGINAL. I CERTIFY THAT THE INFORMATION GIVEN IS TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.

Member Name Date Signed

I verify that all of the information is accurate and that I am the person named above.

Do you have a Common-Law partner?	Yes No
Partner's Date of Birth
If you have a Common-Law partner, provide the date the co-habitation commenced

			Does your partner's health/dental plan cover
Type of Coverage Yes No	Effective Date	Partner's Date of Birth	Your Partner Only	Your Partner and Yourself Only	Your Partner and Children Only	Your Partner You and You Children
Spousal Health Coverage
Spousal Dental Coverage