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Claimants Statement You will need approx When an

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Page 1 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
1 Information about the deceased
Claimant’s Statement
When an insured person passes
away, use this form to submit
a claim for investments or life
insurance benefits.
Information required to
complete the form
You will need approx
15 minutes to complete
Upon review of this form, additional
documents or information may be required.
You will be contacted if additional information
is needed.
A separate form is required for each claimant.
• policy number (if available)
• information about the deceased and their death, including
date and cause of death, funeral home information
• for life insurance, information about the deceased’s recent
doctors and hospital visits
• banking information if you would like to receive payment
by direct deposit
• business number, for corporate beneficiaries
• the deceased’s SIN number, if you are claiming on behalf
of the estate
• name and address of the executor if applicable
NOTICE:
We will be verifying that the claimant is the
correct recipient prior to paying the funds.
If you need more generic guidance on
when and what to do, contact details or
mailing addresses, visit our guide at the
back of this form.
Policy number
Funeral home name Funeral home address
Street address
Province Phone number
Place of death of deceased (Province, Country)
Additional policy number (separate by commas)
Deceased’s name (First, Middle Initial, Last)
Cause of death (Insurance claims cannot be paid without this information)
Suite or apt #
Relationship to the deceased
Date of birth of deceased (dd/mmm/yyyy)
Date of death of deceased (dd/mmm/yyyy)
Funeral home phone number
Date of birth (dd/mmm/yyyy)
Marital status of the deceased (on date of death)
Funeral home information (if known)
In what capacity are you claiming the proceeds:
We use this information to validate the death of the deceased with the funeral home.
2 Information about claimant
Claimant’s name (first, middle initial, last), or company name (for corporate beneficiary)
City Postal code
Provide details for other
Named beneficiary Executor Assignee Trustee Other
continued...
Is your claim for:
A life claim An investment claim Both
( )
( )
Page 2 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
Street address
Province
Suite or apt #
Name and mailing address of executor
2 Information about claimant (continued)
Executor name (first, middle initial, last)
City Postal code
Same as above
Provide the social insurance number (SIN) or business number (BN) for one of the following options.
A different address
Are you a:
Your SIN Beneficiary’s SIN Deceased’s SIN BN used for tax purposes
Quebec business number (if applicable)
The Social Insurance number (SIN) or Business number (BN) is required for reporting of interest and/or other
tax reporting requirements, and to confirm your identity. If the claimant has never been assigned a SIN or BN
number, write “No number”.
3 Claims for investments
If you are only submitting a claim for life insurance, go to section 4, Claims for life insurance
Settlement option: Selection must be in accordance with settlement option(s) provided within letter and/or claim details statement.
Lump sum payment by cheque
Lump sum payment by direct deposit to the Claimant’s bank account at a Canadian financial institution
Not applicable for external registered or non-registered contracts. Provide a personalized void cheque.
Transfer proceeds into a High Interest Manulife Bank Advantage Savings Account
(Provide personalized void cheque; or to apply for an account, contact your advisor or go to www.manulifebank.ca)
These funds are intended as a transfer of death claim benefits as permitted under the applicable provision of the Income Tax Act (Canada). This transfer
will discharge us from all liability with respect to the above-noted policy(ies).
Transfer proceeds to another Canadian financial institution (provide the following for the transfer)
Name of Canadian financial institution Contract or policy number
Address of Canadian financial institution
Internal transfer (provide the following for the transfer)
Policy Number to transfer to Deposit allocation
Beneficiary making
the claim
Trustee making this claim
on behalf of the beneficiary
Representative of
the estate
Representative of a corporate
beneficiary
Phone number
Choose one of the following options:
( )
Page 3 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
3 Claims for investments (continued)
Transit number Institution number Account number
Choose one of the following options for the payment proceeds:
4 Claims for life insurance
Name of financial institution Account holders name
Claimant completing this form
Payment by direct deposit
Advisor of record
You may wish to discuss your options with an advisor.
(Canadian financial institution only) Not applicable for professional and alumni members. Provide a personalized void cheque. Complete the following
if you do not have a void cheque.
Payment by cheque sent to:
$
001 12345 123 1234 1234567
3 digits
Transit Number
Account Number
Continuation Segregated Fund and GIC (RRIF only)
Continue the terms of the contract as owner. Please provide personalized void cheque for Canadian financial institution and date of birth as
requested in section 1.
Continuation Segregated Fund and GIC (Non Registered and RRSP)
Continue the terms of the contract. A new policy number will be assigned for administration purposes only.
To deposit payments directly to your account, attach a personalized void cheque to this page. By selecting this option, you, your heirs, executors,
administrators and assigns agree that any sum or sums of money paid to your bank account after your death will be refunded to us for distribution to
the person(s), if any, entitled to the money under the terms of the contract.
Continue the annuity investment contract, if applicable
If you are submitting a claim for investment products only, go to section 6, Advisor information.
Transfer proceeds into a High Interest Manulife Bank Advantage Savings Account
(provide personalized void cheque; or to apply for an account, contact your advisor or go to www.manulifebank.ca)
Apply to a new or existing policy with us
Include the applicable application or deposit form.
Policy number Include investment and payment details (if applicable)
Transfer under a settlement option with us
(only applicable to annuity settlements already on file) i.e. Term Certain or Life Annuity - Complete an application for annuity, NN0486E.
Other products (type and quantity per day)
Did the deceased, to your knowledge, ever smoke or use tobacco or tobacco cessation products?
5 Medical details about the deceased Life insurance claims only
# of cigarettes per day
Approximate date when the health of the deceased was first affected (dd/mmm/yyyy)
IMPORTANT: Any reference to testing, tests, test results, or investigations excludes genetic tests. Genetic test means a test that analyzes DNA, RNA
or chromosomes for purposes such as the prediction of disease or vertical transmissions risks, or monitoring, diagnosis or prognosis.
How long did the deceased use tobacco or other products?
Yes No Unknown
Page 4 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
5 Medical details about the deceased (continued) Life insurance claims only
Provide the name of the deceased’s usual doctor and any other doctor(s) they attended in the last 5 years. If more space is needed,
use another form or sheet of paper (both must be signed and dated).
Primary Doctor
Primary doctor’s name (Please print) Address
Did the deceased ever stop smoking?
Yes No Unknown NA
If yes, when? If yes, for how long?
Phone number Date (dd/mmm/yyyy) Reason for visit
Other Doctor
Other doctor’s name (Please print) Address
Phone number Date (dd/mmm/yyyy) Reason for visit
Other Doctor
Other doctor’s name (Please print) Address
Phone number Date (dd/mmm/yyyy) Reason for visit
Name and location of all hospitals or institutions where the deceased was treated in the last 5 years.
Hospital or Institution
Hospital or institution (Please print) Address
Phone number Date (dd/mmm/yyyy) Reason for visit
Hospital or Institution
Hospital or institution (Please print) Address
Phone number Date (dd/mmm/yyyy) Reason for visit
Are you working with an advisor to complete this claim?
6 Advisor information
Advisor name (first, last) Advisor code Phone number Email address
Yes No
( )
Page 5 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
7 Authorization and consent
In this section personal information refers to personal information about you.
Collecting, using and disclosing personal information
By signing below, you consent that we may use the personal information about you that we collect to:
• verify your identity and to otherwise uniquely identify you
• evaluate and administer claims with respect to this (these) policy(ies).
In this statement, you and your refer to the policy owner, or claimant under the policy. We, us, our, and the Company refer to The
Manufacturers Life Insurance Company, and our affiliated companies and subsidiaries.
For Manulife Investments, if you are assuming ownership of the contract, you understand and agree that Manulife may collect, use and
store the personal information provided.
Updates to this statement and further information about our privacy practices are posted to www.manulife.ca.
We collect, use, verify, and disclose your personal information for identified purposes, and only with your consent, or as permitted or
required by law. By signing the form, you give your consent for us to collect, use, and disclose your personal information, as set out in this
statement. Any alterations to the consent must be agreed to in writing by the Company.
What personal information do we collect?
We may collect specific personal information about you such as:
• identifying information, such as your name, address, telephone number(s), email address, your date of birth, driver’s license, passport
number, or Social Insurance Number (SIN)
• a personal investigation, financial information, credit bureau report, and/or a consumer report from other organizations, person, or
source that has any information or records about you
• information about how you use our products and services, and information about your preferences, demographics, and interests
• other personal information we may require to administer our business relationship with you.
We use fair and lawful means to collect personal information.
Where do we collect your personal information from?
We collect your personal information from:
• completed forms
• other interactions between you and the Company
• other sources, such as:
- an advisor or authorized representative(s)
- third parties with whom we deal in issuing and administering the policy
- public sources, such as government agencies or internet sites.
What do we use your personal information for?
We will use the personal information we collect to:
• verify your identity and the accuracy of the information you provide
• administer the rights under the policy
• comply with legal and regulatory requirements
• analyze data to make decisions and help us understand our customers better, so we can improve the products and services we provide.
Who do we disclose the information we collect to?
We may disclose information we collect to:
• persons, financial institutions, reinsurers, and other parties with whom we deal in issuing and administering the policy now and in
the future
• authorized employees, agents, and representatives
• your advisor
• any agency that has entered into an agreement with us and has supervisory authority, directly or indirectly over your advisor, and
their employees
• any person or organization to whom you, or the deceased, gave consent
• people who are legally authorized to view your personal information
• service providers who require this information to perform their services for us (for example data processing, programming, data storage,
market research, printing and distribution services, paramedical, credit bureaus and investigative agencies).
The abovementioned people, organizations, and service providers are both within Canada and jurisdictions outside Canada, and would
therefore be subject to the laws of those jurisdictions.
Where personal information is provided to our service providers, we require them to protect the information in a manner that is consistent
with our privacy policies and practices.
Before signing, please read the following important information about the collection and use of any personal information
connected to this Claimant’s Statement.
Page 6 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
7 Authorization and consent (continued)
How long do we keep the information we collect?
We keep the information the longer of:
• the time period required by law and by guidelines set for the financial services industry, or
• the time period required to administer the products and services we provide.
Withdrawing your consent
You may withdraw your consent for us to use your SIN or Business Number, if applicable, for non-tax administration purposes. You may
also withdraw your consent for us to use your personal information to provide you with other service or product offerings, excluding those
mailed with your statements.
You may not withdraw your consent for us to collect, use, retain, or disclose personal information we need to issue or administer the policy
unless federal or provincial laws give you this right. If you do so, a policy may not be issued and benefits will not be payable under the
policy, or we may treat your withdrawal of consent as a request to terminate the policy.
If you wish to withdraw your consent, phone our customer care centre at:
1-888-MANULIFE (626-8543), or 1-888-MANUVIE (626-8843) in Quebec, or write to the Privacy Officer at the address below.
Accuracy and Access
You will notify us of any change to your contact information. You have the right to access and verify your personal information maintained
in our files, and to request any factually inaccurate personal information be corrected, if appropriate. If you have a question, a concern, or
wish to receive more information about parties who have access to your information or about our privacy policies and procedures, and/or
wish to review your personal information in our files or correct any inaccuracies, you may send a written request to:
Privacy Officer
Manulife
500 King Street N.
Waterloo, ON N2J 4C6
Privacy_office_canadian_division@manulife.ca
Please note the security of email communication cannot be guaranteed. Do not send us information of a private or confidential nature by
email. By contacting the Privacy Office via email you are authorizing us to communicate with you by email.
How we resolve complaints
To discuss any questions or concerns you may have, please contact your advisor or our head office at:
1-888-626-8543 in all provinces except Quebec or 1-888-626-8843 in Quebec.
More information about our complaint resolution process is available on the Internet at:
www.manulife.ca under Contact Us > Complaint resolution.
Page 7 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
8 Signatures
By signing below, you are confirming that:
• to the best of your knowledge, all of the information in this Claimant’s Statement is current, correct and complete
• you agree to the terms of this Claimant’s Statement
• you make all of the declarations, acknowledgements and authorizations contained in this Claimant’s Statement
• a copy of this authorization and agreement is as valid as the original document
Provincial legislation in some provinces requires us to inform you that the time limit for taking legal action is set out in the Insurance Act
and/or other legislation that applies to your claim.
FRAUD NOTICE: Any person who knowingly files a claim containing any false or misleading information may be subject to criminal and civil
penalties. In addition, an insurer may deny benefits if false information materially related to the claim or application for insurance was provided by
the applicant or the claimant.
Signed at (city or town, province)
Intial
Signature of claimant
X
Date (dd/mmm/yyyy)
Business phone numberPrimary phone number
For instructions on who needs to sign, refer to the guide at the back of this form.
Write your initials here to confirm that you are the only person authorized to sign on behalf of the corporation and that
it does not have a seal. You must also sign above.
If claimant is an individual, a trust or an estate
Signature of claimant
X
Business phone numberPrimary phone number
Signature of signing officer
X
Business phone numberTitle
If claimant is a corporation or unincorporated entity
For life insurance or
investment claims, send to:
For life insurance or Professional,
Alumni and Retail Members claims:
For Professional, Alumni and
Retail Members claims send to:
Manulife
500 King Street North
PO BOX 1602
WATERLOO ON N2J 4C6
Or, fax to:
For investment claims:
1-877-277-3774
Should you have any questions
about completing this form,
contact your advisor or call our
customer service centre.
Visit www.manulife.ca for
more information.
© 2021 The Manufacturers Life Insurance Company. All rights reserved.
Manulife, Manulife & Stylized M Design, and Stylized M Design are trademarks of the Manufacturers Life Insurance Company and are used by it, and by its affiliates under license.
Accessible formats and communication supports are available upon request. Visit manulife.ca/accessibility for more information.
For Life Insurance: 1-888-626-8543 (Quebec Only) 1-888-626-8843 Outside North America (519) 747-6600
For Investments: 1-888-790-4387 (Quebec Only) 1-800-355-6776
For Professional Alumni & Retail Members: 1-800-268-3763
All provinces except Quebec:
1-877-763-8834
In Quebec: 1-877-271-5494
Manulife
PO BOX 11023
STN CENTRE-VILLE
MONTREAL QC H3C 4V7
Signature of signing officer
X
Business phone numberTitle
Page 8 of 8 NN0760E (03/2021)The Manufacturers Life Insurance Company
Guide
Glossary
How is this form used for life claims?
This form is used to make a claim for the death benefit of a life insurance policy after an insured person dies.
How is this form used for investment claims?
This form is used to make a claim for the proceeds of an investment product such as an annuity, segregated fund contract, GIC, RRIF, or RRSP
after the annuitant dies.
Who are professional, alumni and retail members?
The policy may be part of a professional, alumni or retail association if:
• the insurance was purchased through the policy holder’s affiliation with a professional or alumni association (for example, Engineers Canada
or the Canadian Medical Association)
• the policy holder purchased the insurance without the help of an insurance advisor.
Who should complete this form?
This form should be completed by the person or entity claiming the proceeds from the investment or insurance product.
If a policy has multiple claimants, please send us a separate form for each claimant. For example, if a life insurance contract has 2 named
beneficiaries, each beneficiary must complete and submit this form to claim their portion of the death benefit.
Where do I find the policy or certificate number?
The policy number is found on the contract or billing statement.
Why do we need a Social Insurance Number (SIN) or Business Number (BN)?
We need the SIN or BN when we report interest amounts and/or other tax requirements, and to confirm your identity.
Why do we ask for the deceased’s health information for insurance products?
We use this information to adjudicate the claim according to the terms and conditions of the policy.
Required signature – Individual claimant
If the claimant is an estate or trust, all executors, liquidators, administrators, or trustees must sign this form.
If a person with Power of Attorney is signing on behalf of a claimant, provide a copy of the Power of Attorney.
Required signature – Corporate claimants
For Individual Insurance and Professional, Alumni and Retail Members: If the beneficiary is a corporation, we need signatures and titles of 2
signing officers or the signature and title of 1 signing officer and the corporate seal. If there is no corporate seal, we require the initials of the
signing officer confirming that they are the only person authorized to sign on behalf of the corporation.
For Manulife Investments: If the beneficiary is a corporation, sign according to the corporate resolution and provide a copy of the resolution.
For unincorporated entities, provide documentation that outlines the signing authorities for the entity.
Has your name changed since our files were updated?
If your name is different from what we have in our files, please send us a copy of your name change documentation (for example, a copy of a
marriage certificate).
annuity
a financial product that pays a fixed stream of payments to a person
or entity over a defined period.
assignee
a person or entity to whom the policy has been assigned as collateral
security.
beneficiary
a person or entity designated to receive death benefit proceeds.
claimant
the person or entity who claims the death benefit.
estate
the money and property owned by a particular person when they die.
executor
a person or entity authorized to represent the deceased’s estate.
GIC
Guaranteed Interest Contract.
RRIF
Registered Retirement Income Fund.
RRSP
Registered Retirement Savings Plan.
segregated fund contract
an individual variable insurance contract.
trustee
a person or entity who is appointed to receive the proceeds on behalf
of a beneficiary or claimant (for example, a minor beneficiary).
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Completed 29 March 2022

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