Application for Student Disability Income Insurance

How to apply:

Complete the form below including the banking information and attach a void cheque from the personal account you would like the premiums to be deducted. Do not use a line of credit account.
Submit the completed Application.

Membership Number (if known)

First Name *

Last Name *

Email *

Gender (assigned at birth) *

Male

Female

Please indicate your smoking status *

Non-smoker rates apply to people who have not used any form of tobacco or tobacco cessation products, including e‑cigarettes in the past 12 months.

Non-Smoker

Smoker

Student Disability Income (Available to Medical Students at the University of Manitoba Only)

Elimination Period - 90 days

Benefit Period - to age 65

Select one of the following options: *

Med 1 (up to $1,500 per month)

Med 2 (up to $1,500 per month)

Med 3 (up to $2,500 per month)

Med 4 ( up to $4,000 per month)

Amount Applied For *

Coverage amounts do not automatically increase each year. You must apply to increase coverage.

If you wish to apply for the Future Insurance Option (FIO) and/or the Cost of Living Adjustment (COLA) Option, with proof of good health contact:

Male Non-Smoker < Age 30	Basic Coverage Premium	Sales Tax	Total Due	12 Months Premium
Med 1($1,500)	$108.00	$7.56	$115.56	$231.12
Med 2 ($1,500)	$108.00	$7.56	$115.56	$231.12
Med 3 ($2,500)	$180.00	$12.60	$192.60	$385.20
Med 4 ($4,000)	$288.00	$20.16	$308.16	$616.32

Male Non-Smoker Age 30-39	Basic Coverage Premium	Sales Tax	Total Due	12 Months Premium
Med 1($1,500)	$135.00	$9.45	$144.45	$288.90
Med 2 ($1,500)	$135.00	$9.45	$144.45	$288.90
Med 3 ($2,500)	$225.00	$15.75	$240.75	$481.50
Med 4 ($4,000)	$360.00	$25.20	$385.20	$770.40

Female Non-Smoker < Age 30	Basic Coverage Premium	Sales Tax	Total Due	12 Months Premium
Med 1($1,500)	$130.50	$9.14	$139.64	$279.27
Med 2 ($1,500)	$130.50	$9.14	$139.64	$279.27
Med 3 ($2,500)	$217.50	$15.23	$232.73	$465.45
Med 4 ($4,000)	$348.00	$24.36	$372.36	$744.72

Female Non-Smoker Age 30-39	Basic Coverage Premium	Sales Tax	Total Due	12 Months Premium
Med 1($1,500)	$171.00	$11.97	$182.97	$365.94
Med 2 ($1,500)	$171.00	$11.97	$182.97	$365.94
Med 3 ($2,500)	$285.00	$19.95	$304.95	$609.90
Med 4 ($4,000)	$456.00	$31.92	$487.92	$975.84

For Smoker rates, or for those applicants over age 39, please contact Mark Venton at 204-985-5846 or mventon@doctorsmanitoba.ca.

You will receive a renewal invoice in May for the following year.

To review the Authorizations and declarations with respect to the Disability Insurance policies noted above, click here.

By checking this box, I consent and agree to the foregoing terms and verify that the information I have provided is accurate and complete. *