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LET US HELP YOU PAY FOR 1 SURGICAL 2 MAJOR MEDICAL 3 IN HOSPITAL MEDICAL CARE DOCTORS SERVICES THE COOP 4 IN 1 PACKAGE PLAN INCLUDES ALL THE FOLLOWING SERVICES 1 SURGICAL les recommended by the Ontario 1962 Schedule Fees for the following SURGICAL OPERATIONS FRACTURES and DISLOCATIONS SERVICES of ANAESTHETISTS DIAGNOSTIC XRAYS Up lo per contract year each member and de pendent except when covered In- the Ontario Hospital Services Commission TONSILS and ADENOIDS HERNIA PREGNANCY are subject to a the SURGICAL refractions inline 3 IN HOSPITAL MEDICAL CARE dependent dun 2 MAJOR MEDICAL Mutinied liy the On BENEFITS paid at la Schedule of GUARANTEED PLAN 80S of all eligible expenses from to a maximum of incurred in any twelvemonth period DOCTORS OFFICE or I CALLS DIFFERENTIAL between SPECIAL ISTS and GENERAL RATES DRUGS Ordered on Pi or Riven by be doctor AMBULANCE CHARGE APPLIANCES THERAPY or related by the doctor as LABORATORY SERVICES for outpatients ordered Hospital Major Medical Claim DOCTORS SERVICES AT HOME IN THE OFFICE LIMITED NUMBER OF INJECTIONS After one full years Medical benefits subject loa limit of MEDICAL CHECKUP per person each contract year EYETEST for correction NO MEDICAL EXAMINATION NO ENROLMENT FEE NO AGE LIMITS FOR ADULTS ONE LOW RATE INCLUDES HUSBAND WIFE Y AND ALL DEPENDENT CHILDREN I UNDER YEARS OF AGE SEMIANNUAL PREMIUM SEMIANNUAL PREMIUM 6000 SINGLE LIMITED OPPORTUNITY THIS ENROLMENT ENDS FEBRUARY 15 ECONOMY IN 1 INCLUDES BENEFITS UNDER SURGICAL 2 MAJOR MEDICAL 3 IN HOSPITAL MEDICAL CARE SEMIANNUAL PREMIUM SINGLE FAMILY 3000 FOR FURTHER INFORMATION WRITE OR CALL ON YORK Licensed by The Ontario Department of Insurance phone 8841501 COOPERATIVE MEDICAL SERVICES 31 Y0NGE ST NORTH RICHMOND HILL HERE IS ALL YOU DO TO JOIN 1 FILL OUT APPLICATION ATTACH CHEQUE FOR IlIIST MONTHS PREMIUM MAIL Oil DELIVER TO COOPERATIVE MEOICAI SERVICES ST NORTH RICHMOND HILL ONTARIO Effective dale Medical Insiin MARCH I APPLICATION FOR MEMBERSHIP YORK COOPERATIVE MEDICAL SERVICES ST RICHMOND HILL ONTARIO Dale of Oil 111 imuon Employed by wife or husband Dale of lilrlh DEPENDENT ace I agree Hint the of in application rights benefits if statement materially affects either Hie Enclosed my cheque or money order for Ihe six payable to York Cooperative Medical Services I understand my coverage will begin March 1964 Signature of applicant ONLY ONE APPLICATION IORM NECESSARY FOR EACH SINGLE PERSONS AND OVER MUST APPLICATION APPLICATION FOR MEMBERSHIP or Employed by Dale of DEPENDENT Till III YEARS AGE Date of birth of my or the risk assumed by Cooperative Enclosed my cheque or money order fur the first six month- pie payable to York Cooperative Medical Services I understand my coverage will begin March Signature of applicant