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CONSENT TO CHANGE OF
IRREVOCABLE BENEFICIARY
For CL Head Office Use Only
CL Certificate Number
Please print clearly in INK. The plan administrator should keep a copy of the completed form for their records and send the original to
The Canada Life Assurance Company. For self-administered plans and GroupNet clients who maintain their own plan members’ records:
the plan administrator should attach this form to the plan member’s application.
1. General enrolment
information
2. Privacy
This section explains Canada Life’s
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form will be valid until we receive written notice that you have withdrawn it, subject to legal and contractual restrictions.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 www.canadalife.com.
3. Consent
This section must be signed and
dated in INK by the plan member.
I have read and understand and agree with the contents of the section on this form entitled “Privacy”.
I, the undersigned irrevocable beneficiary under the above mentioned plan, hereby consent to my removal as irrevocable
beneficiary and relinquish and release all rights and interest to any proceeds payable upon the death of the person insured.
For Québec applicants:
I request that this form be in English.
Je demande que ce formulaire me soit remis en anglais.
www.canadalife.com 1-800-957-9777
M6320-1/20 © 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.
Plan number: Division number: Plan member ID:
Plan sponsor:
Plan member name (print):
last name first name middle initial
•
Signature of Beneficiary:
Date:
Name of Beneficiary:
