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Retiree Benefits Enrollment - Quote

Total Premium: $0.00^/month

(applicable taxes included)

Tip: If you decide to enroll, you will have the opportunity to save your application and come back to it later.

Please be advised that rates are evaluated on an annual basis and are subject to change on January 1st of each year.

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Getting Started

^*Required Fields

We have a few questions before we proceed with your application.

^*Do you have any existing Retiree Benefits insurance with Victor Canada?

Yes No Required Field

^*Will you be requesting an effective date within the next 6 months? Tip: 6 months from today is December 1 , 2025

Yes No Required Field

Reminder Service

Please note that we cannot accept an application for an effective date more than 6 months in the future. If you'd like, you can set up a reminder with us and we will contact you closer to your requested effective date.

Please provide your contact information below.

Title

^*First Name

Your first name must be at least 2 letters.

^*Last Name

Your last name must be at least 2 letters.

^*Email

We'll need your email in order to send you a reminder.

Primary Phone Number

Error

^*When do you plan to retire or when do you plan to purchase insurance?

Error

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Profile

^* Required Fields

Policyholder Information:

^*Documents Language:

Required Field

^*Title:

Required Field

^*First Name:

Required Field

^*Last Name:

Required Field

Date of Birth:

Gender:

Contact Information:

^*Phone Number:

Required Field

^*Email Address:

You must enter a valid email address to enroll online.
If you do not have an email address, please contact us for assistance.

^*Verify Email Address:

Please enter a valid email address.

Address:

^*Enter address:

Enter address manually

^*Address:

Required Field

^*Postal Code:

Required Field

Apt/Unit Number:
(Number Only)

^*City:

Required Field

^*Province:

Province Mismatch. Please edit address above or click here to correct province under Basic Information.

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Payment

^* Required Fields

Set up your PAD Agreement

Please read the PAD Agreement and agree to its terms, then enter your banking information below to set up payment of your plan via pre-authorized monthly debit.

I/We authorize Victor Insurance Managers Inc. to withdraw my/our total monthly premium (as determined by my/our plan selections) from the specified account on the first banking day of each month. All persons whose signatures are required to sign on the specified account have agreed to this authorization. All automatic withdrawals from the specified account will be treated as personal withdrawals as defined by the Canadian Payments Association in Rule H-1. I/We will be notified in advance of the initial withdrawal amount, as well as any change in withdrawal amounts, which may vary according to changes in my/our benefits plan (i.e. enrollment in additional plans, annual rate increase). Any refund of premium paid pursuant to this authorization shall be made to the policy owner.

Please note the following important information:

You may cancel your Personal Pre-authorized Debit Agreement at any time, subject to providing written 30-days notice to Victor Insurance Managers Inc. Retiree Benefits, 600 – 55 Standish Court, Mississauga, ON L5R 4B2. You may obtain a sample cancellation form by contacting your financial institution or by visiting www.payments.cawww.payments.ca page opens in a new tab.
You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with your Personal Pre-authorized Debit Agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.payments.cawww.payments.ca page opens in a new tab.

^*I acknowledge that I have read and agree to the terms of the PAD Agreement. Please accept PAD.

^*Account Type:

Required Field

^*Account Holder Name:

Required Field

^*Bank Number:

Required Field

^*Transit Number:

Required Field

^*Account Number:

Required Field

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Summary of Coverage

^* Required Fields

You can rely on Victor

With a history stretching back over 60 years, you can rely on Victor’s experience and know-how to help support you during your retirement. So that you can get the most out of it.

Your Plan

Your Plan Details
	Coverage	Insured	Monthly Premium	Tax

Total Monthly Premium: $0

Please be advised that rates are evaluated on an annual basis and are subject to change on January 1st of each year.

Click here to change your plan

Effective Dates

Policy Effective Date Details

Click here to change an effective date

Payment Details

Declaration

I/We acknowledge that the statements contained herein are true and together with any other forms signed by me/us in connection with this enrollment form the basis for my/our coverage. I/We understand that my/our coverage will begin on the effective date(s) indicated above, provided Victor has received my/our banking information for pre-authorized debit.

^* I acknowledge that I have read and agree to the above Declaration.

“I would like to receive email updates from Victor Insurance Managers Inc. about new coverage opportunities and insights into retiree insurance and lifestyle trends. I understand that I can unsubscribe at any time.

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Street address
City
State		Zip code
Country

This is your time. Make sure you’re ready.

Your Information

Spouse Information

Retiree Benefits Enrollment - Quote

Getting Started

We have a few questions before we proceed with your application.

Reminder Service

Profile

Policyholder Information:

Contact Information:

Address:

Coverage Details

New Coverage Effective Dates

Medical Questionnaire

Payment

Summary of Coverage

Your Plan

Effective Dates

Payment Details

Declaration