FIRST PRINCIPLES
MORTGAGE INSURANCE
Bingham Group Services Corp. (“BGS”) is Canada’s leading Third Party Administrator (“TPA”) and Managing General
Agent (“MGA”) in the business of creating, marketing and administering group creditor insurance products (including,
mortgage insurance products).
BGS assists and supports its Partners in assessing and monetizing their “books of business” at
NO RISK
and
NO COST
to
its Partner(s).
BGS enjoys the:
n
Dominant position in the heavy truck and equipment space (with over 1100 dealer relationships).
n
The leading position in the small-mid cap equipment leasing space.
n
A strong position in the mortgage insurance space.
The Only
TRUE
Group Creditor
Mortgage Insurance Product
PRE-AUTHORIZED DEBIT (PAD) AGREEMENT
APPLICATION/ACCEPT
Group Creditor Mortgage Insurance
Application and Certificate
Group Policy Number: BGS000002
Certificate Number:
First
Middle
Telephone:
Email:
Date of Birth (dd/mmm/yyyy)
Smoker Status
First
Middle
Telephone:
Email:
Date of Birth (dd/mmm/yyyy)
Smoker Status
MORTGAGE BROKER INFORMATION
Name and Address (include Street, City, Province, Postal Code)
Mortgage Number
Telephone:
Dealer Number
Fax Number:
Life Maximum Ages 18 – 69
Life Maximum Term Ages 65 – 69 = Number of months of coverage limited to expire at 70 Disability Maximum Ages 18 – 64
Provincial Sales Tax (Ontario and Quebec)
Monthly Insurance Premium
I, by signing below: 1. Apply under the Group Policy for the insurance checked above. 2. Declare that the information shown in this Application is true and complete and that this Application and any other forms submitted by me in connection with the insurance applied for forms the basis of the insurance certificate issued. 3. Understand that a) a misrepresentation or disclosure made by me in respect of this Application may cause the insurance to be voided and b) if this Application is not accepted for any reason, the Insurer’s liability is limited to a refund of premiums. 4. Authorize any creditor, lender or other party authorized by them to pay the monthly insurance premium on my behalf.
Important Notices: Insurance is voluntary and is not required as a condition of the mortgage. The Insured Applicant and/or Co-Applicant shall have 30 days from the Effective Date of Insurance to cancel the insurance evidenced by the Certificate. Such cancellation may be effected by giving written notice of cancellation to the Insurer, postmarked no later than the 30th day after the Effective Date of Insurance. Upon receipt of such written notice by the Insurer the insurance evidenced by this Certificate shall be deemed to have never been in force and a full refund of the premium shall be paid.
I, by signing below, hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medically-related facility, insurance company, the group policy administrator, the insurance plan sponsor, any investigative and security agency, any agent, broker or market intermediary, any government agency or other organization or person that has any records or knowledge of me or my health to provide to the Insurer or its reinsurers, mortgage broker and subsequent creditor to which the insurance applies if applicable any such information for the purpose of this Application and contract and any subsequent claim. I authorize Foresters Life Insurance Company to consult its existing files for this purpose. A photocopy of this authorization shall be as valid as the original.
I, by signing below, agree that my personal information may be, subject to applicable law, collected, used, and available and/or disclosed to, Foresters Life Insurance Company, its parent company The Independent Order of Foresters, and their respective reinsurers and/or to the insurance plan sponsor, group contract holder, mortgage broker and subsequent creditor to which the insurance applies if applicable, and to each of their respective affiliates, subsidiaries, employees, contractors, consultants, brokers, agents, and service providers, and to any other person(s) you authorize, in writing, for either servicing the group contract or certificate and/ or for audit, regulatory or legal purposes and otherwise as required or permitted by applicable law. You can review such personal information about you, upon written request, except information prepared for, or as a result of, an anticipated or actual claim or civil, criminal or regulatory investigation or proceeding. Send your written request to our Privacy Officer at our mailing address at: Foresters Life Insurance Company, 1660 Tech Avenue, Suite 3, Mississauga, ON L4W 5S8, Attn: Privacy Officer.
I have received and have been given the opportunity to read the Mortgage Insurance Protection Plan Booklet and agree to be bound by its terms.
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Debtor’s Signature – ACCEPT Date (mm/dd/yyyy) Co-Debtor’s Signature (if applicable) – ACCEPT Date (mm/dd/yyyy)
I authorize Foresters Life Insurance Company (“Foresters Life”) to debit monthly from the account identified in the VOID CHEQUE provided with the Application, of which this PAD Agreement forms a part, the total insurance amount shown on page 1 of the Application for purposes of paying for the insurance issued by Foresters Life in response to the Application. You must provide Foresters Life with notice of a change in the account against which the debits are to be made. This pre-authorized cheque plan is for my convenience. The responsibility for payment of premiums remains with each Debtor. Either party may cancel this PAD Agreement at any time upon written notice of at least 30 days to the other party. To obtain a sample cancellation form, or further information on your right to cancel this PAD Agreement, contact your financial institution or visit “http://www.cdnpay.ca”. I have certain recourse rights if any debit does not comply with this PAD Agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on your recourse rights, I may contact my financial institution or visit “http://www.cdnpay.ca”. For inquiries, obtain information or seek recourse with respect to any pre-authorized debit by Foresters Life, you may contact Foresters Life at: 1660 Tech Avenue, Suite 3, Mississauga, ON L4W 5S8 Tel: 1-800-267-8777 Email: “clientservice@foresters.com”. You waive the right to receive pre-notification of the date of the first debit and of a change in a debit amount required as premium, or charges for the insurance in effect, or a change in amount requested by you by whatever means. Monthly withdrawal under this PAD Agreement are __Personal Related __Business Related.
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Account Holder’s Signature – ACCEPT Date (mm/dd/yyyy) Joint Account Holder’s Signature – ACCEPT Date (mm/dd/yyyy) (if signature required) (if signature required)
406859 CAN (01/12)
Principal Amount Insured
Maximum ($500,000)
Monthly Insured
Amount
($3,000 Max/month)
Premium
Life Insurance
Applicant Only Co-Applicant Only Joint Coverage Separate, Non Joint Coverage
Total Disability Insurance
Applicant Only Co-Applicant Only Joint Coverage Separate, Non Joint Coverage
Date of Application (dd/mmm/yyyy)
Insured Mortgage Amount
Financial Institution
Mortgage Term
Annual Taxes
Coverage Type
Last
Address (include Street, City, Province, Postal Code)
Last
Address (include Street, City, Province, Postal Code)
Name and Address (include Street, City, Province, Postal Code)
Telephone:
Fax Number:
CREDITOR INFORMATION
CO-DEBTOR (Natural Person Only)
DEBTOR (Natural Person Only)
DEBTOR AND CO-DEBTOR INFORMATION
INSURANCE INFORMATION
WAIVER OF INSURANCE COVERAGE
I certify that I have been given the opportunity to become insured under the Group Policy but I wish to decline such coverage and I hereby accept any and all risk hereafter referenced with no further recourse whatsoever.
Debtor Declines all insurance coverage contemplated by this certificate. Co-Debtor Declines all insurance coverage contemplated by this certificate.
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Debtor’s Signature – DECLINE Date (mm/dd/yyyy) Co-Debtor’s Signature (if applicable) – DECLINE Date(mm/dd/yyyy)
