Fillable Disability Income Benets Employee Statement Guide (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Disability Income Benets Employee Statement Guide (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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M7413-1/20
canadalife.com • 1-855-755-6729
© 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.
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Disability Income Benefits
Employee Statement Guide
Please follow the steps in this guide to apply for disability benefits.
Your group plan requires you to notify Canada Life of your disability within a certain time after you become disabled. This means you should notify
Canada Life of your disability as soon as possible. To notify Canada Life of your disability, you can fax or mail your employee statement, consent
form, and any other information you want to provide about your claim to the Canada Life Disability Services Office. Fax numbers and addresses of
all Canada Life Disability Services Offices are on our website or you can contact your plan administrator for this information.
STEP ONE - EMPLOYEE STATEMENT AND CONSENT FORM
Complete the employee statement and consent form if you are applying for Short or Long Term Disability benefits, Life Waiver of Premium benefits,
or Early Referral Services.
The completed employee statement provides us with general information about you and your medical details and provides Canada Life with notice
of your disability claim.
A consent form is included with your employee statement. Your signature on the consent form is necessary as it gives us permission to obtain
additional information from your employer, other insurers, your doctor, hospitals, or other care providers to help us review your claim.
We may share personal information, like your functional abilities, restrictions or limitations with your employer when discussing your return to work.
We may share medical information, like your diagnosis, test results, or medical reports with your employer’s Occupational Health Services if they are
involved with your disability claim(s).
STEP TWO - MEDICAL INFORMATION
Your doctor will need to provide us with medical information about how your condition(s) prevents you from working. Print the medical questionnaire
form applicable to your condition and have your doctor complete it. Your doctor can fax or mail the completed form to Canada Life directly.
You can choose the other conditions form if your condition is not a specific diagnosis listed or you can choose the “print all condition forms” if you are
unsure which form to bring to your doctor.
EMPLOYER STATEMENT
Your employer will send an employer statement to Canada Life on your behalf. This statement confirms your coverage, job information, monthly
earnings and other information necessary to assess and administer your disability claim.
If your plan administrator has not provided the employer statement when we receive your employee statement, we will contact your employer directly
for this information.
OUR RESPONSIBILITY
We will begin our review of your disability claim when we receive your employee statement in the Disability Management Services Office. At that time, a
Canada Life representative will contact you to let you know what you can expect throughout the claim process and to obtain any further information
that may be required.
■ ■ ■ ■
Date of Birth: Social Insurance Number:
Home Address:
City / Town: Province / Territory: Postal Code:
■ ■
Mailing Address:
City / Town: Province / Territory: Postal Code:
City / Town: Province / Territory:
■
■
Ext: ■
Email Address:
Your last day of work: (mm/dd/yy) Your first day unable to work: (mm/dd/yy)
■ ■ Describe:
■ When did you return to work? (mm/dd/yy)
■ ■ ■
■ (mm/dd/yy) OR
■
OR
■
What is the nature of the medical condition that is/was preventing you from working?
■ ■
Check the Confidential box if you authorize us to leave a message containing personal
information about your claim at that number. Otherwise, we will only leave a personal
message with callback information at that number.
Your Social Insurance Number is required as your disability
benefit may be subject to income tax deductions.
Enter your email address if you would like Canada Life to communicate with
you by secure email about your disability claim.
■
M7413-1/20
canadalife.com • 1-855-755-6729
© 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.
Employee Statement
To begin the claim submission process, you must complete the Employee Statement and the consent form. Please have your doctor complete a physician’s statement.
These forms should be submitted within ten days of the onset of your disability or, if applying for Long Term Disability or a Life Waiver of Premium benefit, no later
than eight weeks before the end of the waiting period. Benefits may be denied if these forms are submitted later than the notice period in your group contract.
NOTE: Canada Life takes the submission of fraudulent claims seriously and will verify the accuracy of the information given in support of your claim.
I certify that the information given on this claim form is true, correct, and complete to the best of my knowledge.
YOUR INFORMATION
Gender: Male Female Undisclosed Other
Is your mailing address the same as above? Yes No If no, please provide mailing address.
Location where you work:
Home Phone: Confidential
Cell Phone: Confidential
Work Phone: Confidential
CLAIM INFORMATION
During your absence, have you performed any other work? No Yes
Have you returned to work?
Yes
No
Have you returned to (select all that apply): Regular duties and hours Modified duties Modified hours
When do you expect to return to work: Unknown I’m not planning to return
Is your condition work related? No Yes
Disability Income Benefits
Your Employer’s Name:
Your Plan Number: Your Canada Life ID Number:
First Name: Middle Initial: Last Name:
CLAIM INFORMATION (con’t)
■ ■
(mm/dd/yy)
Provide details of the accident
■ ■ In what province did your accident occur?
■ ■ Hospital Name:
Date admitted: (mm/dd/yy) (mm/dd/yy) OR ■
■ ■
Date of surgery:
Type of surgery:
■ ■ ■
Primary Physician:
Specialty:
Address: Phone Number:
■ ■
Provider Name:
Specialty:
Address: Phone Number:
Provider Name: Specialty:
Address: Phone Number:
M7413-1/20
canadalife.com • 1-855-755-6729
© 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.
When did the accident occur?
Is your condition the result of an accident? No Yes If yes, answer the following questions:
Was the accident a motor vehicle accident? No Yes
Were you admitted to a hospital? No Yes
Date discharged: Still hospitalized
Have you had surgery since being off work, or is surgery planned? No Ye s
Is recovery from your surgery the only medical condition keeping you from working? No Yes Unknown
Please provide the following information of your health care provider related to this claim:
Do you have other health care providers related to this claim? No Yes If yes, provide details.
INCOME DECLARATION AND REIMBURSEMENT AGREEMENT
I understand that:
• I am required to apply for disability benefits that I or another member of my family might become entitled to receive because of my disability, and that
I may be asked by Canada Life to reapply or appeal decisions refusing my application(s) where considered appropriate.
• during the time it takes for my application for these other disability benefits to be accepted, or my entitlement to any other reportable income to be
reviewed, Canada Life will continue paying me amounts equivalent to the disability benefit payments I am eligible to receive under the Group Plan,
provided I continue to be eligible for these disability benefit payments under the Group Plan (the “Advance”). The terms “other disability benefits”
and “other reportable income” refer to any of the types of disability benefits and other income mentioned under the Offset, All Source Maximum,
Coordination of Benefits and Subrogation and Right of Recovery provisions under the Group Plan, as well as any other amounts, including damages
for loss of income, that I may receive or become entitled to receive as a result of my disability.
• if I am entitled to receive disability benefits or any other reportable income, this may result in an overpayment (“Overpayment”) that I will be required
to pay back to Canada Life. I specifically give up my rights under any law that qualifies the Advance, the Overpayment, the other disability benefits, or
any other reportable income, as property exempt from seizure.
• Canada Life may reduce my disability benefit payments by the amount of other disability benefits or other reportable income that I receive or become
entitled to.
I agree to:
• notify Canada Life within 15 days of receipt of other disability benefit payments or any other reportable income.
• repay Canada Life within the time frame Canada Life advises me of after I am notified of the Overpayment amount or within a longer period if
Canada agrees in writing. I understand that if the Overpayment is not repaid when due, Canada Life may take all necessary steps to recover the
Overpayment, including withholding the payment of, or recovering the Overpayment from, any benefits payable under the Group Plan.
•
Signature: Today’s date:
• •
• •
• •
•
Plan#
•
Plan#
•
Plan#
•
Plan#
•
!
Name of bank/credit union:
Transit number: Institution number: Account number:
•
canadalife.com 1-855-755-6729
M7395-1/20
© 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.
FINANCIAL INFORMATION
Have you applied for, or are you receiving any income either as a result of your disability or otherwise (please check no or yes)?
• Canada Pension Plan/Quebec Pension Plan or Worker’s Compensation Board Benefits (or similar benefits). No Yes
• Any other income? Examples: automobile accident benefits, employer sponsored STD or sick leave benefits, Employment Insurance benefits, retirement
or pension plan income.
No Yes.
If you answered yes, a
ttach a copy of the initial benefits statement for each type of other income.
• Self employment or other employment income.
No Yes.
If you answered yes, attach a copy of your pay/salary details.
All of the income described above is referred to as “reportable income”.
If you have any of the following coverage with Canada Life or London Life, please select all that apply:
Individual Disability Insurance
Individual Life Insurance
Creditor/Loan Insurance
Critical Illness Insurance
Guaranteed Standard Issue
Note: If you have Guaranteed Standard Issue coverage with Canada Life this form will be used as notice of claim for that coverage as well.
DIRECT DEPOSIT
Provide your banking information or attach a void cheque where you want your disability benefits to
be deposited to. If space is left blank, previously provided banking information for other benefits under
this group plan (i.e. Healthcar
e or Dentalcare) will be used for any disability income benefits payable.
DECLARATION
I declare the information I’ve entered is accurate. I understand and agree to the terms in the Income Declaration and Reimbursement Agreement section. I
also acknowledge that I need to print, sign, and submit my Consent Form to Canada Life.
Your consent
Before we can process your claim for benefits, you must read this agreement and sign in
the signature box below.
Sharing your personal information
We collect, use and disclose your personal information to:
• investigate and assess your claim
• administer your claim and the group benefits plan
• work out a rehabilitation plan to get you back to work
• audit the assessment of the claim.
• manage internal data for analytics purposes
We may also use your social insurance number for income tax reporting and
as an identification number if this is required in the administration of your
benefits.
We may collect and exchange your personal information
with these persons or groups when relevant and necessary
for the purpose above:
• Healthcare and rehabilitation providers
• Insurance and reinsurance companies
• Administrators of the plan, of government benefits and of other benefit
programs
• Your employer, plan sponsor and plan administrator, for the purpose of
discussing return to work planning
• Your employer’s occupational health services
• Your union representative
• Service providers and other organizations working with us, or on behalf of the
other parties mentioned above. We may use service providers outside Canada.
• An auditor authorized by us, your employer, plan sponsor or their agent
Protecting
your privacy
We take your privacy seriously. We
keep all your personal information
in a confidential file in our offices, or
the offices of an organization we’ve
authorized. The only persons with
access to the information are:
• people working at Canada Life and
those we’ve authorized, who need
the information to do their jobs and
manage your claim
• those whom you’ve given access
• those authorized by law both within
Canada and in any other jurisdiction
where your personal information is
held.
For a copy of our Privacy Guidelines
see canadalife.com or you can
write to Canada Life’s Chief
Compliance Officer.
By signing below, you confirm that:
• You have read, understand and agree with the contents
of this form and authorize us to collect and disclose
your personal information.
• Except for audit purposes, your authorization is valid for
the duration of your claim or until you cancel it in writing.
• All statements you have made about your claim are true
and complete
• A photocopy or electronic copy of this authorization is
as valid as the original.
canadalife.com • 1-855-755-6729
M7413-1/20
© 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.
Your group plan number Print your name Telephone number
Your Canada Life ID number Email Address
Enter your email address if you would like
Canada Life to communicate with you by secure
email about your Disability Services claim.
Your signature Date (mm/dd/yyyy)
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Disability Income Benets Employee Statement Guide (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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