Clico Credit Union

Family Indemnity Plan (FIP) Member Enrolment Form

Personal Information

Indentification Information

Beneficiary Information

Please complete a Designation of Beneficiary Form if you are the only person on this form or if all insureds are minors.

Beneficiary 1

Beneficiary 2

Beneficiary 3

Beneficiary 4

Beneficiary 5

Schedule Information

Premium Schedule for the Family Indemnity (FIP) Enrolment

Premium Schedule for the Family Indemnity (FIP): Critial Illness Rider Enrolment

Option 1: Coverage of $50,000

Option 1: Coverage of $100,000

NB: The monthly premium payable for the Primary Insured is based on the issue age and the selected coverage limit, maximum age of entry is 59 years. The premium amount payable for each coverage amount applied for remains the same for that coverage amount throughout the lifetime of the certificate for the Primary Insured, subject to any changes arising from annual premium rate reviews.