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Application for Student Disability Income Insurance

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.

Step 1

Insurance
Step 2

Payment

Section 1: Student Information

Membership Number (if known)

First Name *

Last Name *

Mailing Address (must be an address in Manitoba to qualify) *

City *

Province

Postal Code *

Email *

Phone Number *

Date of Birth *

You must be under the age of 50 to qualify.

Gender *

Male

Female

If other, please specify:

Race, Ethnic or Indigenous Identity

Which of the following best describes your racial, ethnic and Indigenous identity? You can select one or multiple options. If you're unsure, please click here for descriptions.

If other, please specify:

Indigenous Ethnicity *

First Nations

Métis

Inuk/Inuit

Other

If other, please specify:

Start Date

Expected Date of Completion

Smoking Status *

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

Section 2: Insurance Coverage Applied For

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)

Enter the amount applied for: *

The amount must be a multiple of $100.

Enter the amount applied for: *

The amount must be a multiple of $100.

Enter the amount applied for: *

The amount must be a multiple of $100.

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

To apply for the Cost of Living Adjustment (COLA) rider, you will need to apply with proof of good health. To apply for the COLA rider, please contact our insurance team.

Doctors Manitoba Insurance Team

P: 204-985-5888

E: insurance@doctorsmanitoba.ca

Section 3: Pro-rated Premium Calculation

Coverage Effective December 1st. The premiums listed below includes tax and reflect coverage from December 1st to May 31st of next year.

MALE	Under Age 30		Age 30–39		Age 40–49
Coverage	Non-Smoker	Smoker	Non-Smoker	Smoker	Non-Smoker	Smoker
Med 1 ($1,500)	$115.24	$124.84	$144.05	$158.45	$249.68	$273.69
Med 2 ($1,500)	$115.24	$124.84	$144.05	$158.45	$249.68	$273.69
Med 3 ($2,500)	$192.06	$208.07	$240.08	$264.08	$416.13	$456.14
Med 4 ($4,000)	$307.30	$332.90	$384.12	$422.53	$665.81	$729.83

FEMALE	Under Age 30		Age 30–39		Age 40–49
Coverage	Non-Smoker	Smoker	Non-Smoker	Smoker	Non-Smoker	Smoker
Med 1 ($1,500)	$139.24	$148.85	$182.46	$196.86	$297.69	$331.30
Med 2 ($1,500)	$139.24	$148.85	$182.46	$196.86	$297.69	$331.30
Med 3 ($2,500)	$232.07	$248.08	$304.10	$328.10	$496.16	$552.17
Med 4 ($4,000)	$371.32	$396.92	$486.55	$524.96	$793.85	$883.48

The Disability Insurance plan renews June 1st of every year. You will receive an annual renewal invoice in May of every year.

Authorization and Consent

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. *

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Application for Student Disability Income Insurance

Section 1: Student Information

Section 2: Insurance Coverage Applied For

Student Disability Income

Section 3: Pro-rated Premium Calculation

Authorization and Consent