MEMBERSHIP APPLICATION

INSTRUCTIONS

EACH MEMBER MUST COMPLETE HIS OR HER OWN APPLICATION FORM. PLEASE COMPLETE ALL SECTIONS APPLICABLE.

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* Mandatory Fields

Business or Employer Information

* Company Name
* Business Mail Address
* City
* Province
* Postal Code
* Telephone
Fax
* Email Address
Website
Membership in the Microbusiness Resource Group automatically includes an insurance program that is specifically designed for small business owners and employees of companies that do not have an employee benefit plan. Please complete the following to activate your membership.

Insured Member's Information

Please identify Yourself
* Salutation
* First Name
* Last Name
* Home Mailing Address
* City
* Province
* Postal Code
* Phone Number
Fax Number
* Email
* Name of the Beneficiary of the Insurance Policy
* Relationship
* Beneficiary Date of Birth

Additional Insured

The AD&D Policy provides coverage for your spouse or relationship partner and dependent children. Please provide information for spouse or partner and each dependent child.
Name Date of Birth Relationship

Double my AD&D Coverage to $100,000 for just $100.00 more!

TERMS AND CONDITIONS

Membership in the Microbusiness Resource Group is open to business owners, company employees, contractors and/or employed individuals who wish to enjoy the benefits of membership.

Microbusiness Resource Group is a division of Microbusiness Training Centre Inc. Microbusiness Resource Group is a membership organization that will, from time to time, offer products and services to members. By becoming a member you agree to review offers as they become available. The decision to participate in a member offering or purchase goods and services is completely voluntary, with the exception of the WAI, AD&D and CIB insurance program described below, and any future free services provided at no cost to members. While Microbusiness Resource Group strives to offer only goods and services that are felt to be beneficial to members, neither the Resource Group, Microbusiness Training Centre Inc. nor its affiliates and related companies provides any warranty, explicit or implied, that these goods and services may be of value to you as a member. It is your responsibility to determine the value of the goods and services offered and to determine the benefit, if any, to you or your organization. Microbusiness Resource Group, Microbusiness Training Centre Inc. its affiliates and related companies expressly excludes any liability with regard to information, goods or services provided to you by Microbusiness Resource Group during the tenure of your membership.

INSURANCE

Membership in the Microbusiness Resource Group automatically enrolls you in our Weekly Accident Indemnity, Accidental Death & Dismemberment insurance and Critical Illness Benefit insurance program designed exclusively for members. We do not sell insurance. The Insurance included with your membership is administered by Roy Financial Services Inc. on behalf of Resource Group members. The insurance is a contract between you and the issuing Insurance Company and is not a contract between you and the Resource Group. Annual renewal of your membership is necessary to maintain your insurance coverage. Your Insurance benefits include:

Weekly Accident Indemnity (WAI) Insurance

In the event you have an accident (not necessarily work related) and are unable to work, the WAI program will provide you with an Income Replacement Benefit of $400.00 a week for as long as you are unable to earn an income, up to a maximum of 3 years, upon approval of claim by insurer. To be eligible for the insurance you must be under 70 years of age at the time of enrollment. No medical or health questions are required to enroll in the insurance program and your coverage begins the first of the month following enrollment. Your spouse or relationship partner is eligible for membership at the same low membership fee even if they do not work in your business as long as they are gainfully employed at the time of enrollment. You can also provide coverage for your employees at the same low membership fee.

Accidental Death & Dismemberment (AD&D) Insurance

Coverage provides up to $50,000 in accidental loss of life or dismemberment. In addition, your spouse is insured for up to $25,000 and your dependent children are insured for up to $12,500 for accidental loss of life or dismemberment under the AD&D program. If a claim is made, evidence of death resulting from an accident, such as coronerís report and death certificate are required. In the event of dismemberment, medical evidence is required. You have the option of doubling your AD&D coverage to $100,000 (Spouse $50,000, Children $25,000) for an additional $100 a year.

Critical Illness Benefit (CIB) Insurance (Class I Insured Persons Only)

If a Class 1 Insured Person is diagnosed by a Specialist with an eligible covered condition such as Life-Threatening Cancer, Coronary Artery Bypass Surgery, Heart Attack or Stroke, while coverage is in force and survives for 30 days following the date of diagnosis or such longer period, the Insurer will pay such Class 1 Insured Person $5000.00, subject to all limitations and exclusions of the policy. Payment of the Critical Illness benefit is limited to only the first Covered Condition to occur.

By submitting, I have read and agree to the Terms and Conditions of the Microbusiness Resource Group membership.
Please ensure that you have scrolled to the bottom of the Terms and Conditions box. To activate, check the box.
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