B - GENERAL INFORMATION (CONTINUED)
Name of insurer Policy no. Certificate no. Start date of benefits End date of benefits
Benefit amount
Weekly/Monthly
YYYY MM DD YYYY MM DD
W
M
YYYY MM DD YYYY MM DD
W
M
$
$
5
Comments:
Name of financial institution Institution no. Transit/branch no. Account no.
Address - No., street, suite City Province Postal code
D - PERSONAL INFORMATION MANAGEMENT
To be completed for each claim.
I hereby certify that the above answers are full and true. I authorize Desjardins Insurance strictly for the purposes of determining my insurability, managing my
file and settling my claims to: (a) collect from any person or legal entity, or from any public or parapublic organization, only the information deemed necessary
to manage my file. The non-exhaustive list of sources from which information may be collected includes healthcare professionals or facilities, the MIB (formerly
known as Medical Information Bureau), insurance companies, personal information officers or investigation agencies, the policyholder, my employer or former
employers; (b) communicate to the said persons or organizations only the personal information about me that is deemed necessary for the purposes of my file; (c)
when necessary, request an inquiry report about me, and also use the personal information it may have about me in existing files that are now closed.
Provided that I have filled out the appropriate boxes, I authorize Desjardins Insurance to email me at the address provided in section A of this form and I give
Desjardins Insurance permission to leave voicemail about my disability claim at the phone number provided on this form.
I authorize Desjardins Insurance to use or communicate my social insurance number for tax purposes. A photocopy of this authorization is as valid as the original.
Signature of employee: Date:
E - DECLARATION AND
AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
Desjardins Insurance handles the personal information it has on you in a confidential manner. Desjardins Insurance keeps this information on file so that you
may benefit from group insurance services offered by the Company. This information is consulted solely by Desjardins Insurance employees who need to
do so in the course of their work. Desjardins Insurance may compile anonymized personal information for statistical and informational purposes. Desjardins
Insurance may also communicate with plan members to provide them with optimal health management. You have the right to consult your file. You may also
have information corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a written request to the
following address: Privacy Officer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list
to offer its clients an insurance product following the termination of their group insurance. If you do not wish to receive these offers, you may have your name
removed from the list. To do so, you must send a written request to the Privacy Officer at Desjardins Insurance.
Any credit entered in my account in accordance with this authorization will be identified with a DIRECT DEPOSIT transaction code and I acknowledge that
the credit in question shall constitute an amount paid in accordance with this authorization.
This authorization will be effective on
. The authorization will terminate following a 10-day
written notice by either Desjardins Insurance or me.
Signature of employee: Date:
I hereby authorize Desjardins Insurance to deposit my benefit payment through the DIRECT DEPOSIT system into account at the financial institution
indicated below:
C - DIRECT DEPOSIT ENROLMENT Please include a specimen cheque marked “VOID”.
If you have any accident or sickness coverage through a union, society, creditor, mortgage, auto, lodge or other association, through another employer,
under an individual policy, give the following particulars:
VERY IMPORTANT
Please have the Initial attending physician's statement completed and submit the completed forms online, or by mail or fax to:
Desjardins Insurance – Disability Claims.
