I understand that Doctors of BC will use this form to make changes to my existing disability insurance and that changes will be effective the 1st of the month following my residency or fellowship program completion date.
I understand if I cancel any of the above insurance programs and wish to reapply at later date, coverage will not be automatic and I will be required to provide proof of good health at that time.
I declare that my answers on this application are true and complete and I understand that concealment, misrepresentation and false declaration concerning this application will cause the insurance to be void.
As a member of Doctors of BC or the Yukon Medical Association, for the addition of coverage using the GIB option, I understand and agree that (a) if approved, the GIB option amount will become effective on the date the application is received by Doctors of BC, but not prior to the date of the application Option period, (b) the new coverage will have the same exclusion(s) as specifically excluded from the Guaranteed Insurability
Benefit Rider under the original coverage (c) the new coverage shall be subject to the terms of the Rider under which this option is being exercised.
For application to the Physicians’ Disability Insurance Plan, I certify I am a member of the College of Physicians and Surgeons of British Columbia, that I receive remuneration from the Medical Services Plan on either a fee-for-service and/or sessional and/or non-salaried service contract basis and that I am aware of the terms and conditions of the Physicians’ Disability Insurance plan for which I am applying. I agree that any insurance issued in consequence with this application shall not take effect unless, on the date the insurance would be effective, I am actively engaged in my regular occupation.
Electronic Signature Authorization
By signing below, you are confirming that you are the member named in this form and you acknowledge that you are signing this document electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this document.