Medi Card Application

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Medi Card Application

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Keywords:accidental disability program, disability insurance program, mr ms mrs, life insurance program, address driver, time part time, social insurance, mortgage lender, mm yy, contact name, creditor, email, accountant, creditors, date of birth, postal code, dd, full time, phone number, occupation

Added By: doreen

Date Added:Jul 22 2009 6:24PM

License:Attribution Non-commercial No-derivs Public_domain

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If you wish to fax or email your application form, you first have to download the necessary document. Print it, fill in the information and fax or email it to Medicard Customer Service: Toll Free Phone: 1 888 689 9876 Toll Free Fax: 1 888 689 9862 E mail: info@medicard.com

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#font 152 "PJLMBF+ArialNarrow Italic 48 0" i.e. for amounts under ,200. See terms below #font 138 "PJLLKG+ArialNarrow Bold 50 0" Emergency or rush? Please check here. If you are a business owner and interested in deducting 100 of your medical expenses, check here for more information. Please check one: #font 120 "PJLLIF+Helvetica 44 0" , #font 118 "PJLLID+Helvetica Bold 43 0" X X #font 28 "PJLLBD+ArialNarrow 32 0" First Name Initial s : Home Number: Present Address: Apt #: City: Prov.: Occupation:Present Employer Company Name : Contact Name:Employer s Phone Number:Length of Employment: Work Number:Cell Number:Email: Postal Code:How Long At This Address? Last Name: Mr. Ms. OwnRent Monthly Rent or Mortgage: , Mortgage Lender:Social Insurance # Optional : Driver s License # + Province Optional in Qubec : Date of Birth: DD MM YY Parents If Self Employed, State Name of Source of Income Accountant: Accountant s Phone Number: Gross Monthly Income: , Other Income Specify : , Gross Monthly Income: , Other Income Specify : , Mrs. Miss First Name Initial s : Home Number: Present Address: Apt #: City: Prov.: Occupation:Present Employer Company Name : Contact Name:Employer s Phone Number:Length of Employment: Work Number:Cell Number:Email: Postal Code:How Long At This Address? Last Name: Mr. Ms. OwnRent Monthly Rent or Mortgage: , Mortgage Lender:Social Insurance # Optional : Driver s License # + Province Optional in Qubec : Date of Birth: DD MM YY Parents If Self Employed, State Name of Source of Income Accountant: Accountant s Phone Number: Mrs. Miss Date Signature of Co Applicant if applicable Date Signature of Applicant Amount of Financing Required Medical Treatment Centre Doctors Name Patients Name If applicable Approximate Date of Procedure I we are interested in the Optional Creditors Life Accidental Disability Insurance Program. I we understand that it is not required in order to obtain credit. The Creditor s Life Insurance Program protects my our account for the balance of the loan, to be paid in full, if the borrower s should die. The Accidental Disabili ty Program protects my our account for the monthly payment if the borrower s should become totally disabled due to injury. The cost of the insurance will be added to my fixed monthly payments at a cost of ,1.50 per ,100.00 per year for single and ,2.70 per ,100.00 per year for joint insurance. For further information, contact Medicard . Underwritten by subsidiaries of The Canada Life Assurance Company. *Applicable to the fixed monthly payments program only. Credit card Fixed monthly payment 6 mths 1 yr 2 yrs 3 yrs 4 yrs 5 yrs Full Time Part Time Retired Self Employed Student Full Time Part Time Retired Self Employed Student #font 20 "PJLKIF+ArialMT 30 0" CO APPLICANTS INFORMATION If any APPLICANT S INFORMATION TERMS AND CONDITIONS or I we accept this as written notice of MEDICARD, carrying on business as IFINANCE CANADA INC. "IFINANCE" its affiliates, servi ce providers and professional advisors collectively IFINANCE receiving, disclosing, exchanging and using any Collected Information and any other personal informatio n collectively the "Personal Information" about me us for the purposes set out below. IFINANCE, its affiliates and service providers may use any Information relating to me us: a to establish, maintain and administer my our Credit Card; b to determine my our eligibility for products, goods and services offered by IFINANCE including monitoring my our purchase h istory as well as evaluating my our credit standing; c to determine the suitability of benefits, services or enhancements; and or which other product or service offers may be of interest to me us; d to promote and market additional products, goods and services offered by IFINANCE including by means of direct marketing; e to comply with legal and regulatory requirements; f for any other purpose not prohibited by law. I we hereby also authorize any person who is contacted in this regard to provide such information. I we acknowledge that my our consent to "Use of Personal Information" includes: a IFINANCE providing the service provider who accepts the Credit Card for which I we am applying the "Retailer" with IFINAN CE s decision with respect to this application and if my our Card application is accepted, my our Account number and any other information which the Retailer may reasonably require; b The Retailer providing IFINANCE with information related to any loyalty or reward program offered by that retailer where suc h loyalty or reward programs is administered by IFINANCE and IFINANCE s receipt, exchange and use of such information. Credit will be extended by IFINANCE upon approval of this application and I we request an account card be issued to me us and a ny renewal or replacements thereof. All information provided by me us in connection with this application is true, accurate and complete in all respects. I we consent to the creation of a Personal Information file containing credit and other personal information. Only those emplo yees of IFINANCE whose job functions involve assessment of creditworthiness, credit applications, monitoring, processing of payments and matters relating to the purpose of the file, will have access to my our file. I we understand I we can tell you to stop using Personal Information about me us in order to promote and market additional prod ucts, goods and services offered by IFINANCE. I agree that my our Social Insurance Number may be used as an aid to identify me us with credit bureaus and others f or credit history file matching and other administrative purposes. I we also consent to the retention of Personal Information about me us for as long as is needed for the purposes described abov e, even after I we cease to be a customer. In order to ensure the accuracy, completeness and integrity of the credit reporting system, I we specifically consent to the conti nued disclosure of my our Personal Information to credit bureaus even after the loan or credit facility has been retired. #font 4 "PJLKHD+Arial BoldMT 34 0" Tel: 1 888 689 9876 Fax: 1 888 689 9862 medicard.com APPLICATION FOR CREDIT I we understand that the above information the "Collected Information" is being collected for the purpose of obtaining credit from Medicard, a division of Medicard Finance Inc., carrying on business as iFinance Canada Inc. "iFinance" and is warranted to be true and complete. I we hereby authorize and consent to the collection of the Collected Information and to the making by iFinance, its successors and assigns of whatever credit investigations and or employment and income confirmations iFinance or its successors and assigns may deem appropriate from time to time, and to the disclosure, sharing or exchange of the Collected Information and any report or information based thereon for these purposes with credit reporting agencies, and amongst iFinance, its successors and assigns or any company with whom I we have or propose to have a financial relationship. READ ADDITIONAL TERMS AND CONDITIONS BELOW AND SIGN WHERE INDICATED IF YOU ACCEPT THESE TERMS. If approved, iFinance will contact your provider or medical facility. AGREEMENT CONSENT to USE of PERSONAL INFORMATION For application of the Medicard Credit Card

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