• Request for Change

    Doctors of BC Health and Dental Plan

  • INSTRUCTIONS FOR INSURED: Please complete this application to request a change to a Medical Office Staff or Physician insured under the Doctors of BC Health and Dental Plan. You must already be insured under the Doctors of BC Health and Dental Plan to use this form.

    The Insured person should initiate this request and complete the form (not the employer/sponsoring physician).

    The type of request determines whether an employer sign-off is required. If it is required, Doctors of BC administrators will send a DocuSign to employee and employer.

  • What type of coverage is being changed?*
  • Are you also the Sponsoring Physician of the Health and Dental Plan?*
  • Type of Medical Office Staff Change Request select all that apply)*
  • Type of Physician Change Request select all that apply)*
  • Did your coverage under the Doctors of BC Health and Dental Plan begin before January 1, 2018?*

  • You have selected "Refuse health and dental benefits for a Physician (due to alternate coverage)".

    Coverage can only refused for health and dental benefits if you have non-health and dental benefits under the Doctors of BC Health and Dental Plan. Only Physicians first insured with Doctors of BC HBTF plan prior to January 1, 2018 have life and Accidental Death & Dismemberment (AD&D) Insurance. 

    To refuse health and dental benefits for yourself and/or your dependants please complete a termination form.

  • You have selected "Change Beneficiary on Employee Life" for a Physician, but your coverage with Doctors of BC HBTF/Health and Dental plan began after January 1, 2018. Plan design changed on this date and physicians enrolled on or after January 1, 2018 do not have life and accidental death/dismemberment benefits under the Doctors of BC Health and Dental Plan.

    If you are trying to change the beneficiary of Doctors of BC Member life insurance, please use this beneficiary change form.

    Please remove "Change Beneficiary on Employee Life" from your selection above if you have another change to make on your health and dental plan.

  • Sponsoring Physician/Employer Information


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  • Doctors of BC Health and Dental plan administrators will verify the Sponsoring Physician or Designated Authorized Person for this Business account. 

  • Personal Information - Insured Physician or Medical Office Staff


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  • Date of Birth*
     / /
  • Gender*

  • Province/Territory of Residence: Please note that residents of Quebec are not eligible for coverage

  • Name Change

  • Is this a name change for the insured employee or a dependant of the insured employee/physician?*
  • Physician Name Change: Do you intend to change your name across all your Doctors of BC records (including the College of Physicians & Surgeons?)

  • If you intend to change your name across all Doctors of BC records, please contact our membership department at benefits@doctorsofbc.ca and provide proof of name change. Please note that we receive data uploads from the BC College of Physicians & Surgeons so if your name is not updated with the College, it may overwrite our membership data.

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  • Group Life/AD&D Coverage Change

  • Desired Group Life Insurance & Accidental Death & Dismemberment Benefit*

  • Health Insurance - Previously Declined

  • I was previously declined for health insurance coverage and wish to reapply for the plan tier indicated below:*
  • Are you enrolling any dependants?*

  • Benefit Change - late entrant

    A benefit change requires Evidence of insurability. This is a health questionnaire that Doctors of BC administrators will send to you. The questionnaire is submitted to Manulife for review. Approval may take up to 8 weeks, and coverage will begin on the 1st of the month following approval. Approval is not guaranteed.

  • Long-Term Disability (LTD) changes

  • Reason for changing long-term disability (LTD) coverage amount
  • Desired Long Term Disability Coverage Amount*

  • Please note: coverage greater than $1,000 will require the employee to complete an Evidence of insurability form and be approved by the carrier before coverage will be effective

  • The amount of LTD selected should not exceed 85% of gross monthly earnings. Please choose a different amount of long-term disability coverage.

  • Add dependant(s) - Life event

  • Life Event Eligibility Date*
     - -

  • Add a dependant - late entrant

    You've indicated a life event that was more than 90 days ago, or a situation that always requires evidence of insurability. Evidence of insurability will be required to add your dependant. This is a health questionnaire that is submitted to Manulife for review. Doctors of BC administrators will send you the health questionnaire to complete and you will send it to Manulife. Approval may take up to 8 weeks and coverage will begin the 1st of the month following approval. Approval is not guaranteed.

    Premiums may increase as a result of this change.

  • Add a dependant - within life event period

    You are adding a dependant within the 'non-evidence' life event period so their coverage will go into effect the 1st of the month following receipt of this signed Request for Change.

    Premiums may increase as a result of this change.

  • Extended Health and Dental Dependant Information

  • An "eligible dependant" is defined as any person who is:

    • Your legal spouse or a person with whom you have lived for one year and have publicly represented as your spouse
    • Your unmarried dependent (child(ren) under age 22, or under age 25 if a full time-student attending an educational institution recognized by the Canada Revenue Agency (CRA) and entirely dependent on you for financial support.

    Please only include dependants on this form who are NOT already enrolled.
    Example - if you have 1 child and are adding a second child, only include the information for the second child on this application form.


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  • New Dependant #1 Date of Birth*
     / /

  • New Dependant #1 is a child over 24 years of age. If your child is disabled and entirely dependent on you for financial support, please select "Disabled" from the next question. Otherwise, please remove them from this form.

  • Do you want to add another dependant?
  • New Dependant #2 Date of Birth*
     / /

  • New Dependant #2 is a child over 24 years of age. If your child is disabled and entirely dependent on you for financial support, please select "Disabled" from the next question. Otherwise, please remove them from this form.

  • Do you want to add another dependant?
  • New Dependant #3 Date of Birth*
     / /

  • New Dependant #3 is a child over 24 years of age. If your child is disabled and entirely dependent on you for financial support, please select "Disabled" from the next question. Otherwise, please remove them from this form.

  • Do you have additional dependants to add?*

  • Unfortunately, this form only accommodates 3 additional dependants - please finish this application, and then submit the form again with your remaining dependants.

  • Are all dependants listed above, covered by a Provincial/Territorial healthcare plan (i.e. BC MSP, OHIP, etc)*

  • You indicated that not all dependants listed on this application are covered under a Provincial/Territorial healthcare plan. Please remove the ones that are not covered from the e-application and answer the question as "Yes".

    You may enroll employees and dependants within 90 days of them gaining coverage under a provincial/Territorial healthcare plan. Contact insurance@doctorsofbc.ca and we can assist with enrollment.

  • Over-Age Child Dependants

  • You indicated that one or more of your dependants is disabled and dependent on you. Our administrators will contact you - our insurer may require additional forms to maintain coverage for over-age dependants who are not students.

  • Do you have any other dependants ages 22-24 who are full-time students?*
  • Do you have any other dependants ages 22-24 who are full-time students?*

  • Life and AD&D Beneficiary Designation

  • In the event of my death, I name the person(s) below to receive the policy proceeds. To the extent permitted by Law, I reserve the right to change the beneficiary(ies) named below.

    This designation supersedes any previous beneficiary designation and will be applied to all lines of life insurance on the life of the insured named above.

    A beneficiary is the person or organization that will receive your policy’s death benefit. You may change your beneficiary designation at any time.

    If all the primary beneficiaries are no longer alive, any death benefit payable will become payable to the secondary beneficiary. If no beneficiary is designated, benefits will be payable to the Estate.

  • Do you want to name a secondary beneficiary?*
  • Do you want to name another secondary beneficiary?
  • Do you want to name another secondary beneficiary?

  • If designating a beneficiary who is a minor who lacks legal capacity, please appoint a Trustee below who will receive the minor's beneficiary share.

  • Removal of Dependant(s) due to Life Event

  • I wish to cancel all coverage for the following dependant(s) who are no longer eligible for coverage.

  • On what date was this person no longer an eligible dependant*
     - -

  • Please note: termination of dependant coverage will take place on the 1st of the month following receipt of the signed Request for Change form.

  • Our condolences for your loss. 

    Termination of dependant coverage due to death take place on the 1st of the month following the death of your dependant, regardless of when the signed Request for Change form is received.

  • Do you want to remove any other dependants due to a life event?*
  • On what date was this person no longer an eligible dependant*
     - -

  • Please note: termination of dependant coverage will take place on the 1st of the month following receipt of the signed Request for Change form.

  • Our condolences for your loss. 

    Termination of dependant coverage due to death take place on the 1st of the month following the death of your dependant, regardless of when the signed Request for Change form is received.

  • Do you want to remove any other dependants due to a life event?*

  • This form only allows two dependants to be removed per request. Please submit this request and then submit another request for your remaining dependents who should be removed due to a life event.

  • Refusal of Benefits

    Only allowed if similar benefits are currently in-force under a different group policy
  • Are you and/or your dependants insured under a different group health & dental insurance policy?*

  • In order to refuse benefits under the Doctors of BC Health and Dental Plan, you or your dependants must be covered under another similar health and dental policy. Please revise your selections at the top of the form and remove "Refuse benefits"

  • Do you want to refuse health and dental benefits for you and/or your dependants as a result of this other policy?*

  • If you do not wish to refuse health and dental benefits due to alternate coverage, please revise your selections at the top of the form and remove "Refuse benefits"

  • Please Note: If you waive coverage for yourself, you will still be enrolled in Long Term Disability, and Group Life/AD&D benefits (applies to Medical Office Staff only)

  • I refuse Extended Health and Dental coverage as I and/or my dependants are insured under my spouse's group policy.*

  • Please Note: If you waive coverage for yourself, you will still be enrolled in Group Life/AD&D benefits (applies to Physicians first enrolled prior to January 1, 2018 only)

  • Physician Coverage Only: I refuse Extended Health and Dental coverage for my dependants only as they are insured under another health and dental policy.*

  • Please note: evidence of insurability will be required for you and/or your dependants, if you wish to rejoin the Doctors of BC Health and Dental Plan due to alternate coverage terminating. 

  • Authorizations

  • Applicant Acknowledgements:

    (if applicable) I am authorized to disclose information about my spouse and dependants to enroll them in the plan.

    By participating in this Plan, I authorize the following:

    Manufacturers Life Insurance Company (“Manulife”), its agents and service providers, its re-insurers and their service providers to collect, use and disclose relevant information about me to underwrite, administer and adjudicate claims

    Doctors of BC (my plan sponsor) to collect, use, and disclose information about me, my spouse, and dependants necessary for enrollment and administering the plan.

    I declare the information above is accurate and true.

  • Submission and Next Steps

  • Submission Date*
     / /
  • Date Signed*
     / /

  • Employer (Sponsoring Physician) Signatures are required:

    The changes requested require the employer to approve the changes. Please click "submit" to send your request to Doctors of BC. Once we receive the initial submission, you and your employer will receive a DocuSign envelope to complete the change.

    Your request for change form is not considered complete until the DocuSign envelope is complete.

  • Beneficiary Change: DocuSign Signatures are required:

    Your request for change includes a beneficiary change request. These must be signed via DocuSign to be a valid beneficiary designation. Please click "submit" to send your request to Doctors of BC. Once we receive the initial submission, our administrators will send you a DocuSign envelope to complete.

    Your request for change form is not considered complete until the DocuSign envelope is complete.

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