Application for Membership and/or Insurance (Residents and Fellows)

Doctors of BC#*

Name*

First nameMiddle initialLast name

Former name (if applicable)

Date of birth (dd-mm-yyyy)*

Date

SIN:

College number (CPSID):

Province of birth*

Country of birth*

Address*

Street Number or Name

Apartment or Suite #

CityProvince

Postal Code

Email (required for membership, optional for insurance)*

Confirmation EmailBy providing your email, you are authorizing us to communicate with you by email for business purposes

Telephone (preferred)*

Smoking status:*

Non-smokerSmoker

Sex:*

MaleFemale

Medical School you attended*

Date you graduated medical school*

Date

Have you ever been a Doctors of BC member?*

YesNo

If yes, please provide details of previous Doctors of BC membership*

Residency/Fellowship Institution Name*

Type of program (specialty):*

Date you started your residency or fellowship program (dd-mm-yyyy):*

Date

Date your residency or fellowship program is due to be completed (dd-mm-yyyy):*

Date

Year of residency:*

Location of your residency program (hospital and city):*

Are you actively working as a medical resident at least 25 hours per week in your occupation?*

YesNo

If no, explain why:*

Spouse Name*

First nameMiddle initialLast name

Spouse's Former name (if applicable)

Spouse's Date of birth (dd-mm-yyyy)*

Date

Spouse's Province of birth*

state or region

Spouse's Country of birth*

Does your spouse have the same address as you?*

YesNo

Address (if different than member's address)*

Street Number and Name

Apartment or Suite #

CityProvince

Postal Code

Spouse's Email (Required for DocuSign)

Confirmation EmailBy providing your email, you are authorizing us to communicate with you by email for business purposes

Spouse's Telephone (preferred)*

Spouse's Smoking status:*

Non-smokerSmoker

Spouse's Sex:*

MaleFemale

Occupation:*

Annual Income:*

Insurance applications require the consent of the insured if the insured is 16 or older. If any of your children are over 16, we will ask for an email address as they must sign the DocuSign application as well. We keep the email on file solely for the purpose of completing the insurance application, or administering a claim.

Number of children*

Child 1

Child 1 - Eligible dependent child's name*

First NameMiddle NameLast Name

Child 1 - Date of birth:*

Date

Child 1 - Sex*

MaleFemale

Is Child 1 age 16 or older?*

YesNo

Child 1 - Email Address*

Confirmation Emailexample@example.com

Child 2

Eligible dependent child's name*

First NameMiddle NameLast Name

Date of birth:*

Date

Sex*

MaleFemale

Is Child 2 age 16 or older?*

YesNo

Child 2 - Email Address*

Confirmation Emailexample@example.com

Child 3

Child 3 - Name*

First NameMiddle NameLast Name

Child 3 - Date of birth:*

Date

Child 3 Sex*

MaleFemale

Is Child 3 age 16 or older?*

YesNo

Child 3 - Email Address*

Confirmation Emailexample@example.com

Child 4

Child 4 - Name*

First NameMiddle NameLast Name

Child 4 - Date of birth:*

Date

Child 4 - Sex*

MaleFemale

Is Child 4 age 16 or older?*

YesNo

Child 4 - Email Address*

Confirmation Emailexample@example.com

Child 5

Child 5 - Name*

First NameMiddle NameLast Name

Child 5 - Date of birth:*

Date

Child 5 - Sex*

MaleFemale

Is Child 5 age 16 or older?*

YesNo

Child 5 - Email Address*

Confirmation Emailexample@example.com

Child 6

Child 6 - Name*

First NameMiddle NameLast Name

Child 6 - Date of birth:*

Date

Child 6 - Sex*

MaleFemale

Is Child 6 age 16 or older?*

YesNo

Child 6 - Email Address*

Confirmation Emailexample@example.com

Resident term life insurance offer
As a resident, you may apply to purchase $100,000 term life insurance with no evidence of insurability ($100,000 lifetime maximum).

Do you want this $100,000 of term life insurance?*

YesNo

Optional riders - select the riders you want to purchase:*

Waiver of premium riderFuture insurance option riderI do not want to add any additional riders

Do you want to apply for additional life insurance beyond the $100,000 offer? Medical evidence will be required*

YesNo

Additional term life insurance
You may apply to purchase a combined total of up to $5,000,000 term life insurance in units of $50,000 to a maximum of 100 units.

Evidence of insurability is required.

Indicate the amount of coverage you are applying for at this time excluding existing Doctors of BC coverage.

Amount of Member Life Insurance Coverage*

Units you are applying for (1 unit = $50,000)

Optional life insurance riders - select the riders you want to purchase:*

Waiver of premium riderFuture insurance option riderI do not want to add optional riders

Medical evidence
Additional information may be required so that we can assess your application.

Additional requirements may include, but not be limited to, a telephone interview by a carefully screened and trained interviewer who will ask you a series of questions about your medical history, your doctor’s name, and any medications taken. The interview will take approximately 30 minutes.

The information you provide will be sent to Manulife promptly and will be used only for insurance purposes.

Beneficiary designation
This designation supercedes any previous beneficiary designation and will apply to the entire amount of your Doctors of BC life insurance coverage.

You hereby designate the individual(s) named as beneficiary on this application to receive any death benefit payable with respect to the coverage applied for.

If none of the primary beneficiaries are alive, any death benefit payable will be payable to the secondary beneficiary. If no beneficiary is designated, benefits will be payable to your Estate.

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.

Primary beneficiary (share of benefits must add up to 100%)*

	Last name	First name	Middle initial	Relationship to life insured	Amount %	Age if under 19
Beneficiary #1
Beneficiary #2
Beneficiary #3

Secondary beneficiary (share of benefits must add up to 100%)

	Last name	First name	Middle initial	Relationship to life insured	Amount %	Age if under 19
Beneficiary #1
Beneficiary #2
Beneficiary #3

Are any of the beneficiaries named under the age of 19?*

YesNo

Trustee for minor children*

	Last name	First name	Middle initial	Relationship to life insured
Trustee

Amount of Spouse Life Insurance Coverage*

Units you are applying for (1 unit = $50,000)

Optional riders - select the riders you want to purchase:*

Waiver of premium riderFuture insurance option riderI do not want to add any optional riders