Please consult your plan administrator for type of coverage available under your plan. Check ( ) the appropriate box to indicate the type
of coverage for which you are applying.
Page 1 of 2
Please complete both pages of this form.
Group Benefits
Application for Optional Life Insurance for Plan Member and Spouse only
The Manufacturers Life Insurance Company GL4032E (09/2008)
INSTRUCTIONS - Please print all answers
Please ensure that ALL SECTIONS are completed.
Section 1 - Plan sponsor's information - To be completed by plan administrator.
Sections 2, 3, 4 and 6 - Plan member's information - To be completed by plan member.
4.
If required, retain a photocopy for your files.
3. This application MUST BE submitted to Manulife Financial with a COMPLETED Evidence of Insurability form (GL2979E). (Evidence of
Insurability is NOT required if changing status from "Smoker" to "Non-smoker".)
2.
1
Plan number(s) Certificate numberAccount number/Division
Class
Plan sponsor's
information
Plan sponsor
2
Plan member's name (last, first and middle initial)
Language preference/Langue préférée
French/Français
English/Anglais
Sex
Female
Plan member's
information
Male
Have you smoked (cigarettes, cigars, pipe, etc.) or used tobacco in any other form within the last 12 months?
NoYes
Beneficiary designation
information
I appoint ____________________________________________________________________ as Trustee to receive any amount due
to any beneficiary under the age of 18.
For designated beneficiaries
under the age 18.
If a beneficiary is not assigned,
"ESTATE" will be assumed.
3
Spousal coverage
Spouse's name (last, first and middle initial)
Sex
Female
Male
Has your spouse smoked (cigarettes, cigars, pipe, etc.) or used tobacco in any other form within the last 12 months?
NoYes
Note: you will be the
beneficiary of your spouse's
insurance, if you are then
living, otherwise the
beneficiary will be your estate.
4
Note: If the beneficiary is shown as irrevocable, his/her
consent is required to change it. Include a signed and dated
consent with this form. You are responsible for ensuring
the validity of your designation.
If spouse is beneficiary, designation is:
For Quebec residents only
In Quebec, the designation of your spouse as
beneficiary is irrevocable unless otherwise specified.
IrrevocableRevocable
Additional name, if applicable (last, first and middle initial)
Relationship to plan memberAdditional name, if applicable (last, first and middle initial)
Name of beneficiary (last, first and middle initial) Relationship to plan member
PLAN MEMBER ONLY SPOUSE ONLY
1.
PLAN MEMBER AND SPOUSE
Irrevocability
Relationship to plan member
Applicant's present amount of optional life
Additional amount requested
Total amount requested
Optional life amount:
Spouse's present amount of optional life
Additional amount requested
Total amount requested
Spousal optional life amount:
OR x salary ORunits of
$$ $
=
$
x salary OR ORunits of
$$ $
=
$
OR
x salary ORunits of
$$ $
=
$
Eligibility date (dd/mmm/yyyy)
Province of residence
Date of birth (dd/mmm/yyyy)
Annual earnings
$
Date of birth (dd/mmm/yyyy)
OR x salary ORunits of
$$ $
=
$
x salary OR ORunits of
$$ $
=
$
OR
x salary ORunits of
$$ $
=
$
50231
n/a
A--------
n/a
Saint Mary's University
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Certification and
authorization
6
Mailing instructions
5
Please send the completed form to:
Group Medical Underwriting
Manulife Financial
PO BOX 2026
HALIFAX NS B3J 2Z1
Page 2 of 2The Manufacturers Life Insurance Company GL4032E (09/2008)
I certify that I (being the plan member, spouse or dependant with the capacity to contract, whichever is applicable) am
applying for this Group Benefits coverage/insurance ("Coverage") and that the information provided for this application
is true and complete. I
agree that my coverage may be denied or terminated at any time as a result of any false,
incomplete, or misleading information having been provided in this application. I
authorize Manulife Financial
("Manulife") to collect, use, maintain and disclose my personal information relevant to this application ("Information")
for the purposes of Group Benefits plan administration, audit and the assessment, investigation, or management of this
application, and medical underwriting (collectively, the "Purposes"). I
am authorized to consent to the collection, use,
maintenance, exchange and disclosure of Information pertaining to any minor child who may be the subject of this
application for Coverage, for the Purposes, and all of the statements made herein on my own behalf shall apply equally
to such minor child. I
understand that Manulife may investigate this application and may require Information about me
for the Purposes, including information regarding activities, income, employment, education and training, health and
medical history and treatment, including clinical notes. I
authorize any person or organization with Information,
including any medical and health professionals, facilities or providers, professional regulatory bodies, any employer,
group plan administrator, insurer, investigative agency, and any administrators of other benefits programs to collect,
use, maintain and exchange this information with each other and with Manulife, its reinsurers and/or its service
providers, for the Purposes. I
understand that any Coverage shall not become effective until approved by Manulife.
I
authorize the use of my Social Insurance Number ("SIN") for the purposes of identification and administration, if my
SIN is used as my plan member certificate number. I
agree a photocopy or electronic version of this authorization is
valid. I
acknowledge that more specific details regarding how and why Manulife collects, uses, maintains, and
discloses my personal information can be found in Manulife's Privacy Policy and Privacy Information Package,
available at www.manulife.ca/groupbenefits, or from my Plan Sponsor.
Any Information provided to or collected by Manulife in accordance with this authorization, will be kept in a Group
Benefits life, health or disability file. Access to your Information will be limited to:
Manulife employees, representatives, reinsurers, and service providers in the performance of their jobs;
Persons to whom you have granted access; and
Persons authorized by law.
You have the right to request access to the personal information in your file, and, where appropriate, to have any
inaccurate information corrected.
Signature of spouse (required only if evidence regarding insurability of spouse is provided in this form) Date signed (dd/mmm/yyyy)
Signature of plan member Date signed (dd/mmm/yyyy)
Plan member's name (please print)
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