Authorization & consent

Member details

Spouse/
Dependent(s)

Plan coverage

Life/Disability

Coordination of benefits

Direct deposit

Review

Life/Disability

Authorization & consent

I understand that the personal information provided herein as well as any other personal information currently held or collected in the future by Manitoba Blue Cross may be collected, used, or disclosed to administer the terms of the group policy of which I am an eligible member, to develop and recommend suitable products and services to me, and to manage the Company’s business.
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Depending on the type of coverage I carry, limited personal information may be collected from and/or released to a third party. These third parties include other Blue Cross Plans, health care professionals, or institutions, health and life insurers, government and regulatory authorities, and other third parties when required to administer the benefits outlined in my policy or the group policy of which I am an eligible member.
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I understand that my personal information will be kept confidential and secure. I understand that I may revoke my consent at any time; however, if consent is withheld or revoked, the coverage may be denied or rescinded. I understand why my personal information is needed and am aware of the risks and benefits of consenting or refusing to consent to its disclosure. For additional information regarding Manitoba Blue Cross’ privacy policies I can contact Manitoba Blue Cross at 204.775.0151 or 1.800.873.2583 or Manitoba Blue Cross should I have questions as to the collection, use or disclosure of my personal information.

I understand that the personal information and personal health information provided herein as well as any other personal information and personal health information currently held or collected in the future by Manitoba Blue Cross and/or Blue Cross Life Insurance Company of Canada (collectively referred to as “Blue Cross”) may be collected, used or disclosed to administer the terms of the policy in which I am an eligible member, to develop and recommend suitable products and services to me, and to manage the Company’s business.
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Depending on the type of coverage I carry, limited personal information or personal health information may be collected from and/or released to a third party. These include other Blue Cross organizations, licensed physicians and/or any other healthcare professionals or institutions, health and life insurers, government and regulatory authorities, and other third parties when required to administer the benefits outlined in the policy of which I am an eligible member.
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I understand that my personal information and personal health information will be kept confidential and secure. I understand that I may revoke my consent at any time; however, if consent is withheld or revoked, the coverage may be denied or rescinded. I understand why my personal information and personal health information is needed and am aware of the risks and benefits of consenting or refusing to consent to its disclosure. For additional information regarding Blue Cross’ privacy policies as to the collection, use, or disclosure of my information, I may contact Manitoba Blue Cross at 204.775.0151 or at Manitoba Blue Cross .

I authorize Blue Cross to collect, use and disclose my personal information and personal health information as described above.

Member details

Email address

First name

Last name

Gender

Birth date

Mailing address

City

Province

Postal code

Home phone (optional)

Work phone (optional)

ext.

Do you have a Provincial Health Number?

Members must be registered with a provincial health care plan to be eligible for any health plan coverage.

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Yes

Spouse/Dependent(s)

Please complete this section if you have eligible dependents. Dependent children must be under the dependent age of {__} or a full time student under the age of {__}.

Common-law/Spouse

Clear spouse data

First name

Last name

Relationship

Birth date

Gender

Dependent

A dependent child must be:

natural or adopted child of the member or spouse
financially reliant on the member
unmarried or in a common-law relationship
is under the dependent age
is above the dependent age but less than the student age and is attending an accredited educational institution, college or university on a full-time basis

Please see your plan administrator for further details on dependent eligibility.

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Clear dependent data

First name

Last name

Relationship

Birth date

Gender

Disabled dependent

We require one of the following documents when dependent(s) with a disability reach or are over the student age in order for them to remain on or be added to the member plan coverage.

A copy of the Disability Credit Certificate used for Income Tax purposes.
A letter from the dependent’s medical doctor stating the condition and the date the dependent became disabled.
Manitoba Blue Cross Disabled Dependent Form completed by the member and the dependent's medical doctor.

The supporting documents can be sent directly to Manitoba Blue Cross at info@mb.bluecross.ca.

info

Add another dependent Remove last dependent

Additional information

Cohabitation date

Plan coverage options

Review your plan options and select one from each coverage area.

If you require additional information please contact your plan administrator.

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Plan Coverage PDF for JOHN SMITH.

View PDF View PDF

Plan Type Bucket

Plan Coverage

Waive

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Member may waive plan coverage if they have duplicate group benefits through their spouse’s coverage.

Members may waive plan coverage if it is optional.

Plan Type Bucket

Plan Coverage

Waive

info

Member may waive plan coverage if they have duplicate group benefits through their spouse’s coverage.

Members may waive plan coverage if it is optional.

Waived information

Reason

Benefit provider (optional)

Policy number (optional)

Life/Disability

1. Beneficiary

2. Trustee

3. Declaration

4. Optional life rates

Beneficiary(ies)

I hereby designate the beneficiary(ies) entitled to receive the proceeds arising under this plan to the following person(s) below.

First name

Last name

Relationship

Percentage

Add another beneficiary

If a minor has been appointed as a beneficiary, trustee information should be provided.

Adding a trustee?

Yes

First name

Last name

Relationship

Email (optional)

Mailing address

City

Province

Postal code

Phone

ext. (optional)

I hereby revoke any and all previous beneficiary designations in relation to my foregoing coverage(s) and designate the person(s) named on the beneficiary page of this application for this plan upon my death.

At Manitoba Blue Cross, we are committed to making our services more accessible and we are providing you with the option to complete your beneficiary designation electronically. Before we can start using electronic records and related electronic signatures, we need your consent on the following:

By selecting the “I consent” button below, you:

• agree that your electronic signature for your beneficiary designation is a valid form of signature, and consent to using electronic records and signing electronically instead of using paper documents and handwritten signatures;

• understand that your electronic signature is legally binding in the same manner as if you had provided a handwritten signature on a physical document;

• understand that if you are unable to download or print any record or document to which you have attached your electronic signature, such record or document remains valid and legally binding, and you should reach out to Manitoba Blue Cross (“MBC”) directly to obtain a copy of such record or document;

• understand that an electronically reproduced copy of a record or document that you signed and submitted by electronic means (including a photocopy, image or any other electronic copy) is valid as the original document to which you attached your electronic signature initially;

• understand that it is your responsibility to ensure all the information you provide to MBC, including any information you input into this beneficiary designation form, is current and accurate; and

• confirm that you have reviewed and accept MBC's Authorization & Consent in addition to MBC’s Privacy Code.

I consent

I decline

Optional life

OPTIONAL LIFE

Amount

Requested amounts may be rounded to match the units listed in your benefit booklet up to your plan maximum. For further information when applying, please contact your Plan Administrator.

Please specify smoker status:

In the past twelve (12) months, have you used nicotine or any smoking cessation products in any form (including e-cigarettes)?

Non-smoker

Smoker

I do not want this optional coverage

Monthly rate: $0.00

Monthly rates will be added to your coverage if approved. Life and disability benefits are underwritten by Blue Cross Life Insurance Company of Canada.

Optional spousal life

OPTIONAL SPOUSAL LIFE

Amount

Requested amounts may be rounded to match the units listed in your benefit booklet up to your plan maximum. For further information when applying, please contact your Plan Administrator.

Please specify smoker status:

In the past twelve (12) months, have they used nicotine or any smoking cessation products in any form (including e-cigarettes)?

Non-smoker

Smoker

I do not want this optional coverage

Monthly rate: $0.00

Monthly rates will be added to your coverage if approved. Life and disability benefits are underwritten by Blue Cross Life Insurance Company of Canada.

Optional dependent life

Quote provided is per dependent and coverage will apply to all eligible dependents.

OPTIONAL DEPENDENT LIFE

Amount

Requested amounts may be rounded to match the units listed in your benefit booklet up to your plan maximum. For further information when applying, please contact your Plan Administrator.

I do not want this optional coverage.

Monthly rate: $0.00

Monthly rates will be added to your coverage if approved. Life and disability benefits are underwritten by Blue Cross Life Insurance Company of Canada.

Optional accidental death and dismemberment

OPTIONAL ACCIDENTAL DEATH & DISMEMBERMENT

Coverage for:

Member only

Member and family

Amount

Requested amounts may be rounded to match the units listed in your benefit booklet up to your plan maximum. For further information when applying, please contact your Plan Administrator.

I do not want this optional coverage.

Monthly rate: $0.00

Monthly rates will be added to your coverage if approved. Life and disability benefits are underwritten by Blue Cross Life Insurance Company of Canada.

Coordination of benefits

Do you, your spouse, or dependents have coverage for any of the benefits applied for through another benefits plan?

Yes

Benefits provider (optional)

First name

Last name

Relationship

Benefits covered

Select all

Health

Vision

Hospital

HSA

Dental

Drugs

Ambulance

Not specified

Direct deposit

Direct deposit allows Manitoba Blue Cross and/or Blue Cross Life Insurance Company of Canada to deposit claim payments into your bank account.
If any updates are required in the future to your direct deposit information, you can do so through your mybluecross online account or by submitting a direct deposit form to Manitoba Blue Cross.

Transit number

Institution number

Account number

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I hereby authorize Manitoba Blue Cross and/or Blue Cross Life Insurance Company of Canada to deposit all claim payments to the financial institution indicated above.

I do not wish to set up direct deposit at this time.

Review

Member details

Edit

Email address

First name

Last name

Gender

Birth date

Mailing address

City

Province

Postal code

Home phone (optional)

Work phone (optional)

ext. (optional)

Do you have a Provincial Health Number?

Spouse/Dependent(s)

Edit

Common-law/Spouse

First name

Last name

Relationship

Birth date

Gender

Dependent

First name

Last name

Relationship

Birth date

Gender

Disabled dependent

Additional information

Cohabitation date

Plan coverage

Edit

Plans

Dental Service Plan

Life/Disability

Edit

Beneficiary(ies)

First name

Last name

Relationship

Percentage

Tyler

Schmidt

Friend

100 %

Trustee

First name

Last name

Relationship

Email (optional)

Phone

Address

City

Province

Postal code

ext. (optional)

Optional life

None

Optional spousal life

None

Optional dependent life

None

Optional accidental death and dismemberment

None

Life and disability benefits are underwritten by Blue Cross Life Insurance Company of Canada. All amounts are subject to approval.

Coordination of benefits

Edit

Benefits provider

Benefits covered

First name

Last name

Relationship

Health

Direct deposit

Edit

Direct deposit information

Transit number

Institution number

Account number

Card example you will receive in the mail in the coming weeks:

I certify that all information contained herein is correct and authorize payroll deductions if required.

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Authorization & consent

Member details

Spouse/Dependent(s)

Common-law/Spouse

Additional information

Plan coverage options

Waived information

Life/Disability

Beneficiary(ies)

Optional life

Monthly rate: $0.00

Optional spousal life

Monthly rate: $0.00

Optional dependent life

Monthly rate: $0.00

Optional accidental death and dismemberment

Monthly rate: $0.00

Coordination of benefits

Direct deposit

Review