•
STD Form for COVID-19
(
dd/mm/yyyy)
3. Do you
have
an
y other he
alth problems that might affect your recovery (e.g. diabetes, heart disease, respiratory
illness)?
STD Form for COVID-19
Plan Member Name
:
Address:
Plan Number:
Your Employer's Name:
Date symptoms first appeared:
First day absent from work:
Phone Number:
Date of Birth:
Employee ID Number:
(dd/mm/yyyy)
This document contains both information and form fields.
To read information, use the Down Arrow from a form field.
canadalife.com 1-855-755-6729
M7489(COVID)-
4/20
© 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 Member
Confirmation of Illness Form
Please only complete this form if your absence is due to symptoms of COVID-19 and you're pending
test results, or if you have a clinical diagnosis of COVID-19.
In recognition of the increasing pressure on our medical clinics and hospitals due to the COVID-19 pandemic, we
will not, at the outset, require an Attending Physician’s Statement as part of your disability claim submission if
your absence is due to COVID-19 symptoms, or a clinical diagnosis of the virus. This is a time limited exception
as we move through the current situation.
In
the absence of an Attending Physician’s Statement, we require confirmation of your symptoms, your
test
results, and any medical treatment you may have received for your condition. Accordingly, please complete
and sign this form and return it with your Employee Package, which you also need to complete.
1. Please confirm:
2. Please indicate the symptoms associated with
yo
ur illness:
Fever Decreased appetite
Cough Runny nose
Fatigue Nausea
Muscle aches Vomiting
Sore throat Headache
Shortness of breath
Other
