MEMBER ENROLMENT FORM

PLEASE USE BLOCK LETTERS, TYPE OR PRINT WHEN

COMPLETING THIS FORM

 COMPANY INFORMATION (TO BE COMPLETED BY EMPLOYER)

GROUP NUMBER/ACCOUNT/DIVISION NUMBER EMPLOYER/COMPANY NAME

D D M M M Y Y D D M M M Y Y Y N
LOCATION EMPLOYMENT DATE EFFECTIVE DATE OF COVERAGE NEW HIRE

REMARKS

 EMPLOYEE PERSONAL INFORMATION (TO BE COMPLETED BY EMPLOYEE)

FIRST NAME MI LAST NAME

D D M M M Y Y M F MA SI DI WI SE CO
DATE OF BIRTH GENDER OCCUPATION MARITAL STATUS
MA-MARRIED; SI-SINGLE; DI-DIVORCED;
WI-WIDOWED; SE-SEPARATED; CO-COMMON LAW

TRN (MEMBER) CELL NO

HOME ADDRESS

EMAIL ADDRESS

 GROUP health (TO BE COMPLETED BY EMPLOYEE)

DEPENDENTS
LAST NAME FIRST NAME MI GENDER RELATIONSHIP DATE OF BIRTH TRN
M F D D M M M Y Y

M F D D M M M Y Y

M F D D M M M Y Y

M F D D M M M Y Y

PROOF OF AGE FOR DEPENDENTS

BIRTH CERTIFICATE OTHER SPECIFY

 GROUP life (TO BE COMPLETED BY EMPLOYEE)

SALARY Weekly Fortnightly Monthly Annually $

BENEFICIARY NAME RELATIONSHIP LIFE% DATE OF BIRTH GENDER TRN

D D M M M Y Y M F

Trustee Name Trustee TRN

D D M M M Y Y M F

Trustee Name Trustee TRN

D D M M M Y Y M F

Trustee Name Trustee TRN

D D M M M Y Y M F

Trustee Name Trustee TRN

 BANKING INFORMATION (TO BE COMPLETED BY EMPLOYEE)

Bank Name Bank Branch

Account
Account Type Savings Chequing
Name

Account Number

[Link] 888-4-CANOPY p owe re d by

 As provided under my Employer’s Group Contract with Canopy Insurance Limited, I elect coverage on behalf of myself and my eligible dependent(s) as listed overleaf (where applicable) and authorize
my employer to deduct from my earnings the contributions required (if any) for the coverage.
I authorize Canopy Insurance Limited to have access to , and copies of, all medical, hospital or other institution/agency records relating to the diagnosis,treatment or service provided to me or a
covered dependent.

SIGNATURE OF EMPLOYEE DATE

NAME OF AUTHORIZED OFFICER OF EMPLOYER POSITION OF AUTHORIZED OFFICER OF EMPLOYER

COMPANY STAMP SIGNATURE OF AUTHORIZED OFFICER OF EMPLOYER DATE

b bHEALTH HISTORY QUESTIONNAIRE

(IF EMPLOYEE IS APPLYING FOR COVERAGE OUTSIDE OF ELIGIBILITY PERIOD, PLEASE COMPLETE THE HEALTH HISTORY QUESTIONNAIRE)

THIS HEALTH HISTORY QUESTIONNAIRE IS BEING COMPLETED FOR: Employee Only Employee & Dependents Dependent(s) only

NAME HEIGHT WEIGHT GENDER RELATIONSHIP DATE OF BIRTH TRN

M F D D M M M Y Y

M F D D M M M Y Y

M F D D M M M Y Y

M F D D M M M Y Y

b bPERSONAL HEALTH HISTORY

(NOTE: IF QUESTIONNAIRE IS BEING COMPLETED FOR NEW DEPENDENTS, GIVE DETAILS ONLY FOR DEPENDENTS)

YES NO
FOR THE EMPLOYEE
1. Are you employed by the employer named on this form for more than 30 hours per week?

FOR THE EMPLOYEE AND/OR DEPENDENTS KINDLY RESPOND ‘YES’ OR ‘NO’ TO THE FOLLOWING QUESTIONS.
2. During the last 5 years, have you or any of your dependents consulted, been examined or treated by a Doctor, or been advised to have any diagnostic
tests (e.g. blood tests, X-Rays, CAT Scan, MRI) etc.?
3. During the last 5 years, have you or any of your dependents undergone a surgical operation, or been treated in any hospital or other institution?

4. Have you or any of your dependents been treated for, or been told that you have Heart Trouble, Blood Disease, High Blood Pressure, Kidney Disorder,
Diabetes, Tuberculosis, Cancer, Tumour, Ulcer, Asthma, Epilepsy, Alcoholism, Mental Disorder, or any other disease not listed anywhere on this application?
5. Have you or any of your dependents been diagnosed with, or treated for HIV, AIDS, or ARC (AIDS related complications) (If ‘Yes’, underline disease.)

6. Are you or any of your dependents now receiving, contemplating, or been advised to seek any medical attention or surgical treatment, or taking any
medication?
7. Do you or any of your dependents have any disorder of the female organs or breast?

8. Are you or any of your dependents now pregnant?

9. Do you or any of your dependents have any physical impairments?

10. Do you or any of your dependents have any prior or existing history of alcoholism or drug abuse?

11. Have you or any of your dependents ever had an application for Life or Health Insurance declined,
postponed, rated or modified in any way?

IF THE RESPONSE TO ANY OF QUESTIONS 2-11 IS ‘YES’, GIVE COMPLETE DETAILS BELOW (CONTINUE ON ANOTHER SHEET, IF NECESSARY)

QUESTION FULL NAME OF PERSON TREATED NATURE OF AILMENT DEGREE OF RECOVERY: (FULL, NAME AND ADDRESS OF ATTENDING MEDICAL DATE OF
NO. PARTIAL OR CONTINUING) PROFESSIONAL VISIT

I declare that all the statements on this form are full, true and complete, and I understand that they form the basis upon which any insurance will be made effective. I authorize the physician, hospital
or other medically related facility to disclose to Canopy Insurance Limited information about my health, habits or medical history, as well as that of any dependents listed above. It is further understood
that Canopy Insurance Limited reserves the right to request an examination by a Physician of their choice to aid its decision.

SIGNATURE OF EMPLOYEE DATE

b bTO BE COMPLETED BY EMPLOYER (IF APPLICABLE)

YES NO If YES give detail

1. Is the employee absent from work and unable to perform his/her duties?
2. Has the employee been absent from work for more than 1 week due to sickness or injury
during the past 6 months?
3. Do you know of any prior or existing serious physical impairment, history of drug abuse or
alcoholism?

NAME OF AUTHORIZED OFFICER OF EMPLOYER SIGNATURE OF AUTHORIZED OFFICER OF EMPLOYER

POSITION OF AUTHORIZED OFFICER OF EMPLOYER DATE

[Link] 888-4-CANOPY p owe re d by