Authorized Signature: Date:
Name (please print): Title:
Phone:
Fax:
E-Mail:
Name: First Initial Last Employee I.D. or Cert. Number
Address: Street & Number P.O. Box City Province Postal Code
Name Plan Number Division Number (if applicable) Class (if applicable)
Address: Street & Number P.O. Box City Province Postal code
Telephone Number Fax Number
Date of Employee’s Employment (MM/DD/YY) Effective Date of C.I. for Employee (MM/DD/YY)
Amount of C.I. for Employee Effective Date of C.I. for Dependent(s) (MM/DD/YY)
Amount of C.I. for Dependent(s)
Date of Birth
(MM/DD/YY)
Employee or Dependent
Division Number
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Application for Group Critical Illness Benefits
Employer’s Statement
Important:
The completed Employer’s and Employee’s Statements are required before claim assessment can commence. These forms should be submitted
to Canada Life within the established criteria. Canada Life’s Privacy Guidelines and applicable law allow employees to have access to personal
information in their files. Please be aware that any information you provide us in connection with these services may be subject to access by the
employee.
Instructions:
Please provide a copy of the enrolment form to validate Critical Illness enrolment. If an enrolment form is not available, print screen will be accepted
as confirmation. Please ensure that the print screen indicates Critical Illness Insurance for themselves and for any/all dependents.
A. EMPLOYER IDENTIFICATION
B. EMPLOYEE IDENTIFICATION
C. EMPLOYMENT INFORMATION
DECLARATION
I HEREBY DECLARE THAT THE ANSWERS TO THE ABOVE QUESTIONS ARE ACCURATE AND COMPLETE.
Submit to: The Canada Life Assurance Company
Creditor Insurance - Critical Illness Unit
330 University Avenue, S3
Toronto ON M5G 1R8
GroupCIClaims@canadalife.com
Toll Free 1.866.907.2395
Fax 416.552.6557
301 CAN-2/20
© 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.
