Group Insurance Enrollment

Please fill in if you are requesting couple coverage.

Pre-Authorized Debit (PAD); Pre-Authorized Credit (PAC); **Please upload a VOID cheque or form from your financial institute to set up pre-authorized debits and direct deposits.

At ASSOCIUM and ASSOCIUM Benefits, we recognize and respect the importance of privacy. When you enrol for insurance coverage or submit a claim, we establish a confidential file and collect, use and disclose your personal information for the purposes of issuing, administering, adjudicating and/or servicing your group plan. You may access and correct, if needed, the personal information in your file by sending us a request in writing. We limit access to your personal information to our staff and other persons we have authorized who have a need to know it to perform their duties. If you have any questions regarding our privacy policies or about the collection, use and disclosure of your personal information, please contact our Privacy Officer at ASSOCIUM, 1 Concorde Gate, Suite 802, Toronto, Ontario, M3C 3N6.

I hereby apply for group benefits coverage and authorize the deduction from my bank account and remittance to ASSOCIUM Benefits any contributions required under the group benefits plan. I hereby authorize ASSOCIUM, ASSOCIUM Benefits, MDM Insurance Services Inc. (MDM), the group plan administrator, their agents, or any other person or organization having any relevant information regarding me or my spouse to release and exchange any and all information necessary for the purposes of determining eligibility for benefits and administration of the group benefits plan. I authorize ASSOCIUM Benefits, and MDM to deposit all payments due to me from the benefit plan, into the bank account that I have identified. I confirm that this direct bank deposit authorization applies to the financial institution herein named by me and any other financial institution I choose to name in the future; and shall remain valid until revoked in writing by me. I understand and agree that upon the deposit of any payments into the account ASSOCIUM, ASSOCIUM Benefits, and MDM are fully discharged from any further liability with respect to such payments. I also understand and agree that ASSOCIUM, ASSOCIUM Benefits and MDM may, at any time and without prior notice, discontinue the direct deposit of payments. I also acknowledge and agree that any payment made by ASSOCIUM, ASSOCIUM Benefits or MDM into the account, to which I am not entitled, either by contract or by law, shall not form part of my property, and shall be immediately refunded to ASSOCIUM, ASSOCIUM Benefits or MDM, either by me or by representatives of my estate. I authorize ASSOCIUM, ASSOCIUM Benefits and MDM and the group plan administrator to correspond with me through the email address identified on this form regarding my coverage. I understand such correspondence may contain information; and that the information is being sent in a manner that is not guaranteed as a secure means of communication. I agree that ASSOCIUM, ASSOCIUM Benefits, MDM and the group plan administrator are not liable for damages which may incur as a result of interception by a third party of an electronic transmission sent by ASSOCIUM, ASSOCIUM Benefits, MDM, or the group plan administrator or by me pursuant to this authorization. Additionally, by submitting this authorization, I, as a member under this policy, authorize MDM to release to and exchange with ASSOCIUM and ASSOCIUM Benefits, all personal information regarding myself, and my Insured spouse, including health and dental claims information. I confirm I am authorized to act on behalf of my spouse for the above such purposes. I declare the information provided is true, complete and accurate. Any copy of this authorization shall be valid as the original. I agree to hold harmless ASSOCIUM, ASSOCIUM Benefits and MDM and its employees for any violation under the federal legislation, PIPEDA. I understand this authorization will be valid until the earliest of termination of membership under this policy, or unless canceled in writing by myself.