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
■
■
■
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• Page 1 of 2
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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.
APPLICATION FOR OPTIONAL
GROUP AD&D COVERAGE
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
Information
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)
Percent
allocated
Relationship
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.
