Plan number: Division number: Benefit Class:
Plan sponsor:
Plan member ID: Cost centre (if applicable):
Effective date of coverage: Month Day Year
Occupation: $
Plan member province of residence: Plan member province of employment:
Plan member name (print):
last name first name middle initial
Date of birth: Month Day Year
Please print clearly in INK.
Street address:
City: Province: Postal code:
Current Optional AD&D amount: $
(if no current amount, please indicate that with a zero)
Total Optional AD&D amount being applied for: $
(current plus additional amount being applied for)
last name first name middle initial
last name first name middle initial
Please print clearly in INK.
last name first name middle initial
Page 1 of 2
This document contains both information and form fields. To read information, use the Down Arrow from a form field. 1-800-957-9777
M6708-1/20 © The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance
Company. Any modification of this document without the express written consent of Canada Life is strictly prohibited.
For CL Head Office Use Only
CL Certificate Number
Please print clearly and complete both sides of this form, in INK. Section 1 is to be completed by the plan administrator and sections 2 through 6 are to be completed
by the plan member.
1. Plan Sponsor Section
This section is to be completed by
the plan administrator.
Earnings: per year month week hour
2. Plan Member
This section is to be completed by
the plan member.
Gender: Male Female Undisclosed Other
Plan member mailing address:
3. AD&D Benefit Amount
This section is to be completed by
the plan member.
Coverage Amount Elected
Employee only coverage
Employee and dependant coverage
4. Beneficiary Designation
This section must be completed to
designate a beneficiary for your life
benefits, 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).
Beneficiary’s name(s)
to plan member
To be divided as follows: As per the percentage indicated above, or
In equal shares to the survivor(s)
You may change this beneficiary designation at any time upon notice to Canada Life. If you wish to make the beneficiary
designation irrevocable (meaning you may not change the designation or make certain changes to your coverage under
the plan without the written consent of the beneficiary) please complete form #M6348 BIL.
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 their 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.
For All Other Applicants - If designating a beneficiary who is a minor or who lacks legal capacity you may wish to appoint a
trustee/administrator by completing form #M6242 BIL. This appointment may not be suitable for all purposes.
Before designating a trustee, you should seek legal advice.
Plan member signature: Date:
Page 2 of 2
5. Privacy
This section explains Canada Lifes
commitment to privacy.
At The Canada Life Assurance Company we recognize and respect the importance of privacy.
Your personal information:
When you apply for coverage, we establish a confidential file that contains your personal information like your name,
contact information, and products and coverage you have with us. Depending on the products or services you apply for and
are provided with, this may also include financial or health information. Your information 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.
Who has access to your information:
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 and to persons to whom you have granted access. In order to assist in fulfilling the purposes
identified below, we may use service providers located within or outside Canada. Your personal information may also be
subject to disclosure to public authorities or others authorized under applicable law within or outside Canada.
What your information is used for:
Personal information that we collect will be used for the purposes of determining your eligibility for products, services or
coverage for which you apply, providing, administering or servicing products or coverage you have with us, and for
Canada Life’s and its affiliates’ internal data management and analytics purposes. This may include investigating and
assessing claims, paying benefits, and creating and maintaining records concerning our relationship.The consent given in this
form will be valid until we receive written notice that you have withdrawn it, subject to legal and contractual restrictions. For
example, if you withdraw your consent, we may not be able to continue to adjudicate or administer a claim for benefits.
If you want to know more:
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
6. Authorizations and
This section must be signed and
dated in INK by the plan member.
I hereby apply for coverage under the group benefits plan issued by Canada Life.
I have read and understand and agree with the contents of the section on this form entitled “Protecting Your Personal
I authorize:
my plan sponsor to deduct from my pay and remit to Canada Life the plan member contributions required under the
plan, if applicable;
Canada Life to use my social insurance number for tax reporting purposes and as an identification number where it is
required in the administration of the plan;
Canada Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators
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.
If applying for coverage for my spouse and/or dependants, I confirm that I am authorized to act on their behalf.
I agree that a photocopy or electronic copy of the 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.