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:

Gord Brennan 204−985−1140 gbrennan@doctorsmanitoba.ca or Mark Venton 204−985−5846 mventon@doctorsmanitoba.ca

Male Non-Smoker < Age 30	Basic Coverage Premium	Sales Tax	Total Due
Med 1($1,500)	$90.00	$6.30	$96.30
Med 2 ($1,500)	$90.00	$6.30	$96.30
Med 3 ($2,500)	$150.00	$10.50	$160.50
Med 4 ($4,000)	$240.00	$16.80	$256.80

Male Non-Smoker Age 30 – 39	Basic Coverage Premium	Sales Tax	Total Due
Med 1($1,500)	$112.50	$7.88	$120.38
Med 2 ($1,500)	$112.50	$7.88	$120.38
Med 3 ($2,500)	$187.50	$13.13	$200.63
Med 4 ($4,000)	$300.00	$21.00	$321.00

Female Non-Smoker < Age 30	Basic Coverage Premium	Sales Tax	Total Due
Med 1($1,500)	$108.75	$7.61	$116.36
Med 2 ($1,500)	$108.75	$7.61	$116.36
Med 3 ($2,500)	$181.25	$12.69	$193.94
Med 4 ($4,000)	$290.00	$20.30	$310.30

Female Non-Smoker Age 30 – 39	Basic Coverage Premium	Sales Tax	Total Due
Med 1($1,500)	$142.50	$9.98	$152.48
Med 2 ($1,500)	$142.50	$9.98	$152.48
Med 3 ($2,500)	$237.50	$16.63	$254.13
Med 4 ($4,000)	$380.00	$26.60	$406.60

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. *

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