Policy No. I undertake to appoint, where required, suitable competent persons, in writing, in terms of the requirements of OHSA and the Regulations and to charge him/them with the duty of ensuring that the provisions of OHSA and Regulations as well as the Council’s Special Conditions of Contract, Way Leave, Lock-Out and Work Permit Procedures are adhered to as far as reasonably practicable. I further undertake to ensure that any subcontractors employed by me will enter into an occupational health and safety agreement separately, and that such subcontractors comply with the conditions set. I hereby declare that I have read and understand the appended Occupational Health and Safety Conditions and undertake to comply therewith at all times. I hereby also undertake to comply with the Occupational Health and Safety Specification and Plan. Signed at .......................................on the......................................day of....................................20….
Policy No. I undertake to appoint, where required, suitable competent persons, in writing, in terms of the requirements of OHSA and the Regulations and to charge him/them with the duty of ensuring that the provisions of OHSA and Regulations as well as the Council’s Special Conditions of Contract, Way Leave, Lock-Out and Work Permit Procedures are adhered to as far as reasonably practicable. I further undertake to ensure that any subcontractors employed by me will enter into an occupational health and safety agreement separately, and that such subcontractors comply with the conditions set. I hereby declare that I have read and understand the appended Occupational Health and Safety Conditions and undertake to comply therewith at all times. I hereby also undertake to comply with the Occupational Health and Safety Specification (Attached in Annexure A) and Health and Safety Plan provided by our company based on the client’s documented Health and Safety Specifications contemplated in regulation 5(1)(b). Signed at .......................................on the......................................day of....................................20….
Policy No. Basic Accidental Death and Dismemberment
Policy No. 9.1.5 Application: CMHRC Date of Policy No.: 9-1-99 Date of Revision: 5/23/05 Referral Process (Continued):
Policy No. THIS ASSIGNMENT is made by the undersigned Employee effective this 16th day of November, 1998.
Policy No. Long Term No.
Policy No o re account debtor o in an insured amount of (pounds)o, dated o;
Policy No. Annual Premium ---------- -------------- DO66760 $2,837
Policy No. Long Term Disability during first months of payments, when you are able to work in your regular occupation on a part-time basis but you choose not to; after months of payments, when you are able to work in any gainful occupation on a part-time basis but you choose not to; the end of the maximum period of payment; the date you are no longer disabled under the terms of the plan; the date you fail to submit proof of continuing disability; the date your disability earnings exceed the amount allowable under the plan; or the date you die. WHAT DISABILITIES ARE NOT COVERED UNDER YOUR PLAN? Your plan does not cover any disabilities caused by, contributed to by, or resulting from your: intentionally self-inflicted active participation in a riot loss of a professional license, occupational license or certification attempt to commit or commission of a crime under provincial or federal law commission of a crime for which you have been convicted under provincial or federal law condition. Your plan will not cover a disability to war, declared or undeclared, or any act of war. UNUM will not pay a benefit for any period of disability during which you are incarcerated. WHAT IS A CONDITION? You have a condition you received medical treatment, consultation, care or services including diagnostic measures, or took prescribed or medicines in the months just prior to your effective date of coverage; or you had symptoms for which an ordinarily person would have consulted a
Policy No. Long Term Disability health care provider in months just prior to your effective date of coverage; and the disability begins in the first months after your effective date of coverage. Any increase benefit will be subject to this condition WHEN DO YOU NOTIFY UNUM OF A CLAIM? Written notice of a claim should be sent within days after the date your disability begins. However, you must send UNUM written proof of your claim no later than days after the date your disability begins. If it is not possible to give proof within days, it must be given no later than year after the time proof is otherwise required except in the absence of legal capacity. The claim form is available from your Employer, or you can request a claim form from us. You must notify us immediately when you return to work in any capacity. HOW DO YOU FILE A CLAIM? You and your Employer must fill out your own sections of the claim form and then give it to your attending doctor. Your doctor should fill out his or her section of the form and send it directly to UNUM. WHAT IS NEEDED AS PROOF OF YOUR CLAIM? Your proof of claim, provided at your expense, must show: that you are under the regular care of a doctor, as defined in the policy; the appropriate documentation of your monthly earnings; the date your disability began; the cause of your disability; the extent of your disability, including restrictions and limitations preventing you performing your regular occupation; and Effective February I, (7)
