A deposit is required from each applicant. Please CURRENT DATE this cheque; it will be cashed upon receipt.
Make it out in an amount equal to the premium listed for the plan you have chosen.


This money will be held in trust for you while you remain on the plan. This amount ensures there is
NO DISRUPTION in your coverage in the event of banking problems (e.g. insufficient funds.)


Your first month’s premium cheque will cover your premium for the first month that you are covered by the plan and each 

payment following that will be paid by automatic withdrawal.

Date this cheque for the FIRST of THE MONTH in which your coverage is to be effective. Make it out in an amount which 

is equal to the premium listed for the plan you have chosen.


Please make all cheques payable to:
HCP GROUP INSURANCE PLAN
1032 Brock Street South
Whitby, ON L1N 4K7


Note: If you are making an application for Optional Life Insurance (Employee/Spouse/Child) please be sure to include a completed Form 4.
This worksheet calculates any additional premium which would apply following approval. DO NOT add any additional costs to the premium amount 

you fill in on your cheques. Any premium owing for optional coverage will be added to your automatic monthly withdrawal after approval is granted.  

Reminder: BOTH cheques are to be fully complete with date, payee, amount and signature fields filled out. BOTH cheques should be drawn from 

the same account you wish all future HCP automatic payments to be drawn from.