Group Policyholder Name (Full Legal Name):
Group Policy Number(s):
Division Number(s):
Monthly withdrawal day (choose from 1 - 20):
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M6942(SPAC)-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.
Copy of the Terms and Conditions
Business Pre-Authorized Debit (PAD) Agreement
To be given to Group Policyholder
Healthcare Spending Account Medical Reimbursement Plan
The effective date of the first withdrawal will occur on the policy effective date or the date in which the new group was
processed, whichever is later.
Important note(s): If there is a different bank account or monthly withdrawal date, a separate form is required. Please
provide this PAD agreement and an unsigned blank cheque marked “VOID” to your Canada Life group representative.
Terms and Conditions of PAD Agreement
Authorization Note: References in this form to “this PAD agreement” include later amendments to it.
Reference in this PAD agreement to “we” and “our” refers to the Group Policyholder (Payor) indicated above.
We authorize The Canada Life Assurance Company (Canada Life) and the nancial institution named above (or any other
nancial institution we may authorize at any time) to withdraw from our account any payments that we have agreed to
make under the listed above group policy(ies), and/or as otherwise specied to be made in this PAD agreement as though
we had personally signed a cheque. We understand that changes to the Group Policy(ies) including as applicable, to
premium amounts or to the method or required amount of payment (including changes requested to this PAD agreement) or
termination and recommencement of automatic payments under this PAD agreement may increase or decrease the amount
withdrawn or to be withdrawn from our account. Accordingly, we authorize such increases or decreases, waiving any
pre-notication requirement with respect to them.
We agree that a photocopy or electronic copy of this PAD agreement will be as valid as the original.
Signatures We certify that all persons whose signatures are required to authorize this PAD agreement have signed below, including any
required joint account holder.
Account changes We will notify Canada Life if our nancial institution, branch or account number changes. To continue withdrawals without
interruption, notice of any change is required 14 days before the change effective date. Canada Life may, but is not obligated
to, rely on verbal instructions from us to amend this authorization.
Confirming
withdrawals
We agree to regularly review our account information and if we question or disagree with the amount withdrawn or any
account changes, we will notify Canada Life in writing within 10 days of the withdrawal or account changes; otherwise, we
agree that the withdrawal or account changes will be considered to have been properly made.
For questions related to these withdrawals we may contact Canada Life.
Non-sufficient
funds (NSF)
information
If there is not enough money in our account to cover the total amount due (“due” as an amount owing, or as an amount
otherwise specied to be withdrawn under this PAD agreement), we authorize Canada Life to immediately make a second
attempt to withdraw the amount due (which may be greater than the amount due at the rst attempt). If the second attempt
is also returned NSF (or if Canada Life decides, in its sole discretion, not to make the second attempt), we understand that
pre-authorized payments will be suspended, and possibly cancelled by Canada Life. We understand that we are responsible
for any NSF charge(s).
Assignment We hereby waive any requirement of prior written notice to us by Canada Life of the assignment by Canada Life of
this PAD agreement.
Cancellation This PAD agreement may be cancelled if any withdrawal is not permitted or is reversed by the nancial institution, or upon
30 days written notice given by us to Canada Life or by Canada Life to us.
To obtain a sample cancellation form, or for more information on your right to cancel this PAD agreement, contact your
nancial institution or visit www.cdnpay.ca. To obtain more information on your PAD agreement, contact your Canada Life
representative.
We agree that if pre-authorized payments are suspended, the method of payment may automatically be changed by
Canada Life, in its sole discretion, to whatever it then offers on a non pre-authorized debit basis. Canada Life, in its sole
discretion, may require a new written PAD agreement if this PAD agreement is cancelled for any reason.
Recourse We have certain recourse rights if any debit does not comply with this PAD agreement. For example, we have the right
to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain
information on our recourse rights, we may contact our nancial institution or visit www.cdnpay.ca.
Contact information For more information about this PAD agreement, contact Canada Life at selectpacPAD@canadalife.com or call 1-204-946-
7696.
