last name first name middle initial
last name first name middle initial
last name first name middle initial
Policy number: ID number:
Policyowner name:
last name first name middle initial
Please print clearly, in INK.
Please print clearly, in INK.
Please print clearly and complete this form, in INK.
Trustee last name first name middle initial Relationship to plan member
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Canada Life and design are trademarks of The Canada Life Assurance Company.
Please keep a copy of the completed form for your records and send the original to
The Canada Life Assurance Company at the address provided on bottom of page 2.
1. General Enrollment
2. Beneficiary
This section is to be completed
by the policyowner.
This section must be completed
to designate a beneficiary
for your death benefit under
the accidental death and
dismemberment and specific
loss benefit rider, if applicable.
The original of this form will be
required for a life claim.
Crossed out beneficiary
designations must be initialed.
I hereby revoke all previous beneficiary designations and designate the following as beneficiary(ies).
to plan member:
Note: If percentages are allocated, they must total 100% (if percentages are allocated to some beneficiaries but
not all, those beneficiaries who do not have allocations are considered to have been allocated equal percentages
to cover the unallocated balance). If no percentages are allocated, the beneficiaries are considered to be allo-
cated for equal percentages. The percentage allocation for any beneficiary who does not survive the insured is
divided equally among those beneficiaries who do survive the insured.
You may change this beneficiary designation at any time upon notice to Canada Life. If you wish to make a beneficiary
designation change please contact Canada Life at the phone number provided on the back of this form.
Note: Where Quebec law applies and you have designated your married spouse or civil union spouse as
beneficiary, the designation will be irrevocable unless you check the box marked “Revocable”, below.
I hereby make the above beneficiary designation:
Revocable, I may change this beneficiary designation at any time
For Quebec Applicants Only - Benefits payable under this plan to a beneficiary who, at the time payment is to be
made, is a minor or lacks legal capacity, will be paid to his/her tutor(s) or curator(s), unless a valid trust has been
established for the benefit of the beneficiary, by Will or by separate contract, to receive any such payment and
Canada Life has been provided notice of the trust. If a valid trust has already been established, designate the trust
as the beneficiary in this section. Before designating a trust, you should seek legal advice.
3. Trustee Appointment
You may wish to appoint a
trustee/administrator by
completing this section
The original of this form will be
required for a life claim.
If designating a beneficiary who is a minor or who lacks legal capacity you may wish to appoint a trustee/
administrator by completing this form. This appointment may not be suitable for all purposes.
If you are designating a trustee/administrator, we recommend you consult with a legal advisor, and with any
proposed trustee/administrator.
Do not complete this section if you have made another trustee/administrator appointment.
I hereby appoint the following trustee to receive and to hold in trust, on behalf of any beneficiary, money payable to
the beneficiary under this policy where, at the time payment is to be made, the beneficiary is a minor or otherwise
lacks legal capacity. Any such payment, to its extent, will release The Canada Life Assurance Company from further
liability. The trustee shall act prudently and may use the money, including any returns on it or investments made,
for the education and/or maintenance of the beneficiary. The trust will terminate once the beneficiary is of the age
of majority and has legal capacity. At that time, the trustee shall deliver to the beneficiary all assets held in trust.
Plan member signature: Date:
Page 2 of 2
4. Privacy
This section explains
Canada Life’s
commitment to privacy.
Protecting Your Personal Information
At The Canada Life Assurance Company, we recognize and respect the importance of privacy. When you apply
for coverage, we establish a confidential file that contains your personal information. This file is kept in the offices
of Canada Life or the offices of an organization authorized by Canada Life. You may exercise certain rights of
access and rectification with respect to the personal information in your file by sending a request in writing to
Canada Life. Canada Life may use service providers located within or outside Canada. We limit access to personal
information in your file to Canada Life staff or persons authorized by Canada Life who require it to perform their
duties, to persons to whom you have granted access, and to persons authorized by law. Your personal information
may be subject to disclosure to those authorized under applicable law within or outside Canada. Personal information
that we collect will be used for the purposes of determining your eligibility for coverage and administering the group
benefits plan. This includes investigating and assessing claims, and creating and maintaining records concerning our
relationship. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies
and practices (including with respect to service providers), write to Canada Life’s Chief Compliance Officer or refer to
5. Authorizations and
This section must be signed
and dated in INK by the plan
I have read and understand and agree with the contents of the section entitled “Protecting Your Personal
I authorize:
Canada Life, any healthcare provider, my plan administrator, any insurance or reinsurance company, admin-
istrators of government benefits or other benefits programs, other organizations, or service providers working
with Canada Life or the above to exchange personal information, when relevant and necessary to determine
my eligibility for coverage and to administer the plan.
I agree that a photocopy or electronic copy of this Authorizations and Declarations section is as valid as the original.
I certify that the information given is true, correct and complete to the best of my knowledge.
For Quebec applicants: I request that this form be in English.
Je demande que ce formulaire me soit remis en anglais.
Please send this form to: The Canada Life Assurance Company
330 University Avenue
S4 – Individual Health Services
Toronto ON M5G 1R8
Phone 1.800.565.4066
Fax 1-800-259-8947