I confirm that:
- I am between 18 and 64 years of age;
- I am a resident of Canada;
- I am the primary cardholder of an eligible credit card with Laurentian Bank of Canada (the “Bank”);
- I have agreed to the disclosures and agreement governing the Laurentian Bank Visa* card I have selected, as may be updated, modified, improved or replaced from time to time; and;
- My eligible credit card account is in good standing and is not restricted.
I would like to apply for Assur-Payment™, group insurance policy No. 9000-V issued to the Bank by Industrial Alliance Insurance and Financial Services Inc. (the “Insurer”).
I understand that the Assur-Payment™ program is an optional service related to the Bank issued credit card I have selected. I acknowledge that only I, the primary cardholder, am authorized to add or remove the Assur-Payment™ program from my credit card account.
I acknowledge that I have received and read the insurance product summary and the fact sheet and have been informed of the contents of the optional insurance, the exclusions, and the procedures to follow when submitting a claim.
I understand that restrictions and exclusions (including pre-existing conditions) may restrict my coverage under the certificate and that they are described in full in the certificate of insurance, a sample of which is available on the Bank website at www.laurentianbank.ca and which will be provided to me upon enrolment.
I accept that a monthly fee (or insurance premium) of $0.97 per $100 of the unpaid credit card balance that appears on my monthly credit card statement applies for this service.
I authorize the Bank and the Insurer to charge the insurance premium to my credit card account, which premium may then be added to the credit card balance.
I acknowledge and agree that if insurance benefits are paid out by the Insurer, they will be paid directly to the Bank.
I understand I may cancel the Assur-Payment™ program and its insurance benefits free of charge by notifying the Bank of my right to cancel within 30 days of signing this application.The Bank must cancel my Assur-Payment™ program effective on the day that is the earlier of:
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i) the day on which the billing cycle ends, or
- ii) 30 days after the cancellation notice is received.
The Bank must refund or credit me with the amount of any fees paid or added to the credit card balance. Thereafter, I may cancel the program at any time by writing to the Bank or calling toll-free at 1-800-522-1846, in which case the program will be cancelled on the next statement of account, and previously charged fees will not be reimbursed.
I confirm that the products and services available were presented to me, the options reviewed, and the products selected were determined by me, alone, to be appropriate for me, having regard to my circumstances, including my financial needs.
For more information on the product and fees, contact Client Services toll-free at 1-800-522-1846.
™ Trademark of Laurentian Bank of Canada.
Job Loss Coverage, we pay monthly benefits of 20% of the eligible balance: