-
Date the employee signed their enrollment form requesting to be added to the plan with group coverage: (MM/DD/YY)
The employee’s coverage effective date. The date the employee was added to the plan with group coverage:
(MM/DD/YY))
Basic life insurance amount for the employee:
n n Amount of optional life insurance:
n n Date premiums stopped being paid:
Company Name: Plan Number:
First Name Middle Initial Last Name Canada Life ID Number Division Class
If plan is taxable provide
Date of Birth
(MM/DD/YY) Social Insurance Number Home Phone Number Cell Phone Work Phone
Home Address City/Town Province Postal Code
Job title: Effective date of hire: (MM/DD/YY)
n n n n n n
n n
n n n n
n n n n n
n
Description:
Date employment ended: (MM/DD/YY)
•
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Disability Application for
Group Life Waiver of Premium Benefit
Employer Statement
The Employer’s and Employee’s Statements should be completed and sent to Canada Life at least 8 weeks before the waiting period ends. Canada’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 this claim may be subject to access by the employee.
Ensure all sections are completed to prevent any delay in assessing this claim
.
EMPLOYEE IDENTIFICATION
EMPLOYMENT INFORMATION
Employee’s gross earnings prior to disability: Hourly Weekly Bi-weekly Semi-Monthly Monthly Annually
Complete every question in this section including a), b), and c).
Employee is:
a) Full-Time Part-Time
b) Permanent Temporary Seasonal Contract
c) Hourly Salaried Commissioned Salaried and Commissioned Hourly and Commissioned
Other
Regular number of scheduled hours: Weekly Bi-weekly Monthly
Do the scheduled hours vary (excluding overtime)? Yes No
COVERAGE INFORMATION When the employee enrolled and was added with coverage under this plan.
Does the employee have any optional life insurance?
No Yes
Are premiums still being paid? Yes No
