Fillable Form 1: Employees information (completed by plan administrator) (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Form 1: Employees information (completed by plan administrator) (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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  • 13 check-boxes
  • 189 other fields

Country of origin: CANADA
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Date of employment Annual earnings Plan administrator's name Plan administrator's Phone No. Plan administrator's email address
MMM/DD/YYYY XXX-XXX-XXXX
Date authorized
n
MMM/DD/YYYY
Employee last name First name Middle initial ID no.
n
n n n
MMM/DD/YYYY
Name of group policyholder (Employer) Policy no. Division no. Benefit class
n n n
n n n
n n n
n
n
n
n
n
n
.............. ..............
n
...................................
n
MMM/DD/YYYY
Page 1 of 5
■
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Please print all answers and complete in INK only (blue or black)
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M6129-7/20 © 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.
EVIDENCE OF INSURABILITY
Coverage Detail
Instructions:
Ensure that all required sections are completed. An incomplete form may result in a delay in processing.
Sections 1-3: To be completed first by the Plan Administrator. Retain a copy of the completed section for your files.
Section 3: To be reviewed, signed and dated by the employee; including completion of the smoking and beneficiary declarations
(if applicable).
Sections 4-5: To be completed by the employee/spouse and submitted to Canada Life. Retain a copy for your files.
Employee to send the form directly to Canada Life via mail/email.
1
Employee’s information (completed by plan administrator)
Is the employee currently actively at work?
Yes
No
If no, please indicate reason and Expected Return to Work Date.
Maternity/Paternity On Claim / Personal LOA / Other
Plan administrator's authorization
I hereby certify that the information on this Coverage Detail form is accurate.
2
Reason for application (completed by plan administrator)
New Enrolment
*Late Applicant (Eligibility Period Expired) Complete section 3 (A)
Increase Coverage Complete applicable portion of section 3 (B) or (C)
Annual Enrolment - Effective Date: Complete applicable portion of section 3 (B) or (C)
* Application for Group Coverage, or Group Coverage
Change Form, must be included.
3
Benefits requested (completed by plan administrator)
A
For Late Applicants
Employee Spouse Children
Basic Life
Healthcare
*Dental
Short Term Disability
Long Term Disability
*Dental Restrictions may apply. Refer to employee booklet or contract.
B
Excess Coverage
Current amount New total amount applied for
Life
Basic
Supplemental
Short Term Disability
Long Term Disability
Clear
Print
Page 2 of 5
Benefits requested (continued)
3
n n
■
n
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n n n n
▶
▶
▶
Signature Date
MMM/DD/YYYY
Please print clearly, in INK.
C
Optional Coverage
New employees and their spouses may elect, without evidence, within 31 days of eligibility, Optional Critical Illness Insurance up to the
Non-Evidence Maximum (NEM) amount for their group plan. The NEM must be confirmed by plan administrator. (Step 3 below).
Applicant (1) Current Amount (2) New total amount
applied for
(3) Amount available
without evidence (NEM)
(confirm with plan
administrator)
(4) Amount applied for
with medical evidence
(Steps 2-3)
If plan is % of salary,
total % applied for:
Employee
Optional Life
Optional Critical Illness
Spouse
Optional Life
Optional Critical Illness
Child
Optional Life
**Medical questionnaire not required if applying for the NEM amount. Overall maximum for optional critical illness insurance is $250,000.
Smoking Declaration (completed by member)
In the past 12 months, have you used any form of tobacco, nicotine products or nicotine substitute? This includes: cigarettes, e-cigarettes/vaporizers,
cigarillos, pipe, cigars, chewing tobacco, nicotine patch and/or gum, hookah/shisha, or such products in any other form.
EMPLOYEE:
Yes
No SPOUSE:
Yes
No
Optional Life Beneficiary Designation (completed by member)
This section must be completed to designate a beneficiary for your life benefits, if applicable. The original of this form will be required for a life
claim. Crossed out beneficiary designations must be initialed.
I hereby revoke all previous beneficiary designations and designate the following as beneficiary(ies).
First Name Last Name
Middle
Initial
Date of birth
MMM/DD/YYYY
Percent
allocated
Relationship to employee
To be divided as follows: As per the percentage indicated above, or In equal shares to the survivor(s)
The Beneficiary for the spousal or child coverage shall be the employee if living, otherwise the estate. I hereby revoke all previous beneficiary
designations and designate the following as beneficiary(ies).
NOTE: Where Quebec law applies: and you have designated your married spouse or civil union spouse as beneficiary, the designation will be
irrevocable unless you check the box marked “Revocable”, below.
I hereby make the above beneficiary designation: Revocable, I may change this beneficiary at any time
An irrevocable beneficiary designation cannot be changed without the written consent of the irrevocable beneficiary. A revocable beneficiary
designation can be changed at any time without consent of the revocable beneficiary.
Plan Member's Signature
M6129-7/20
Page 3 of 5
Instructions: Please print all answers and complete in INK only (blue or black)
Ensure that all required sections are completed. An incomplete form may result in a delay in processing.
■
Sections 1-3: To be completed first by the Plan Administrator. Retain a copy of the completed section for your files.
■
Section 3: To be reviewed, signed and dated by the employee; including completion of the smoking and beneficiary declarations
(if applicable).
■
Sections 4-5: To be completed by the employee/spouse and submitted to Canada Life. Retain a copy for your files.
■
Employee to send the form directly to Canada Life via mail/email.
EVIDENCE OF INSURABILITY
n n
n n
n n
n n
MMM/DD/YYYY
n n
n n
MMM/DD/YYYY
n n
n n
MMM/DD/YYYY
Employee last name First name Middle initial Date of birth
n n
n n
MMM/DD/YYYY
Spouse last name First name Middle initial Date of birth
n n
n n
MMM/DD/YYYY
Home mailing address Street City Province Postal Code
Email address
Mobile phone number Alternate contact number / extension
XXX-XXX-XXXX XXX-XXX-XXXX XXXX
Name of group policyholder (Employer) Policy no.
-
-
Home mailing address Street City Province Postal Code
Email address
Mobile phone number Alternate contact number / extension
XXX-XXX-XXXX XXX-XXX-XXXX XXXX
Applicant Information
4
Member and dependant details (completed by the member)
Employee information
Gender
Male
Female
Undisclosed
Other
NOTE: If you provide your email address, we may use it to communicate
with you about this application.
NOTE: If you provide your mobile number, we may use it to communicate
messages with you about this application.
Spouse information (if applicable) only required if you are applying for dependant coverage.
Gender
Male
Female
Undisclosed
Other
NOTE: If you provide your email address, we may use it to communicate
with you about this application.
NOTE: If you provide your mobile number, we may use it to communicate
messages with you about this application.
Child Information (if applicable) only required if you are applying for dependant coverage.
Child Last Name Child First Name Gender Date of Birth
MMM/DD/YYYY
Child (1)
Male
Female
Undisclosed
Other
Child (2)
Male
Female
Undisclosed
Other
Child (3)
Male
Female
Undisclosed
Other
Child (4)
Male
Female
Undisclosed
Other
Testing font size 9 Testing font size 9 Testing font size 9 Testing font size 9 Testing f
Testing font size 9
Testing font size 9 Testing font size 9 Testing font
Testing font size 9 Testing font size 9 Testing font
__________
n n
__________
n n
EE __________
n n
SP __________
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
n n
EVIDENCE OF INSURABILITY
Page 4 of 5
Height Weight
EE
SP
Yes No
EE
SP
CH
Yes No
EE
SP
CH
Yes No
E
SP
CH
Yes No
EE
SP
No
EE
SP
CH
Yes No
EE
SP
CH
Yes
E
Medical & Lifestyle
Questionnaire
5
Personal Medical History and Lifestyle Information
Genetic Non-Discrimination Act
You should not tell us about any genetic test (that is, any analysis of DNA or RNA chromosomes) which you may have had done. However, you must
tell us if you’re having treatment for, or experiencing symptoms of a genetic condition. You will be asked to provide us full information about your
family history, including all genetic conditions.
If you answer ‘yes’ to any of the health questions, Canada Life will require more information to assess your application.
In this case, a representative of Canada Life will contact you to complete a health assessment.
EE = Employee SP = Spouse CH = Child(ren)
1. What is your current height and weight?
We need an accurate current measure, not an estimate.
feet/inches m/cm pounds kg
feet/inches m/cm pounds kg
2. Have you ever been treated for, or had any known indication of:
• Conditions or issues affecting your heart, blood, circulation, high blood pressure, high cholesterol, immune system such as
HIV or AIDS, breathing such as tuberculosis, emphysema, COPD, sleep apnea or asthma (excluding non-smokers with mild/
seasonal asthma), or any other lung or respiratory problems
• Conditions, issues or injuries affecting your brain or nervous system, such as aneurysm, stroke, concussion, epilepsy,
seizures, numbness, multiple sclerosis, ALS, Huntington’s, Parkinson’s
• Conditions or issues affecting your esophagus, stomach, pancreas, liver, gall bladder or bile duct, intestine, colon, bladder
(excluding resolved bladder infections), kidneys, prostate or reproductive system, such as Crohn’s disease or colitis
• Loss of speech, loss of sight, loss of hearing or any condition affecting your eyes or ears
You do not need to tell us about ear tubes, vision corrected with eye glasses/contact lenses or minor infections which
have completely resolved
• Any form of cancer, tumor (benign or malignant), diabetes, abnormal blood sugar or sugar in the urine, hepatitis, or lupus
• Any bone, joint, muscle or skin condition, such as arthritis, psoriasis, ankylosing spondylitis or back pain, that ever
require(d) medication or treatment
You do not need to tell us about a muscle or bone injury, or minor infection, from which you have completely recovered
• Any conditions or issues affecting your behaviour or mental health, such as anorexia nervosa, bulimia, depression, bipolar
disorder, self-harm, schizophrenia, stress, or anxiety, requiring medication, treatment or time off work/school
3. Other than for a regularly scheduled physical or routine check-up, are you currently undergoing or awaiting any consultations
or exams, or recommended, scheduled or pending tests or test results, treatment or procedures, including surgery, for any
health issues, symptoms or conditions?
Other than an uncomplicated pregnancy, vasectomy, dental surgery, cosmetic surgery or a muscle/joint or bone injury
which you have fully recovered from, this includes (but is not limited to): biopsies, ECGs, x-rays, CT scans, MRIs, blood
tests, ultrasounds, endoscopies, colonoscopies, pap tests, mammograms.
4. Do any of your immediate biological family members (parents, siblings, children), suffer or have suffered from any of the
following:
• Alzheimer’s Disease
• Amyotrophic lateral Sclerosis (ALS
or Lou Gehrig’s Disease)
• Cancer
• Cardiomyopathy
• Dementia
• Diabetes
• Heart Disease
• Huntington’s chorea
• Motor Neuron disease
• Multiple Sclerosis
• Parkinson’s Disease
• Polycystic Kidney disease
• Retinitis Pigmentosa
• Stroke
• and/or any other hereditary medical
condition
5. In the past 12 months, have you used any form of tobacco, nicotine products or nicotine substitute?
This includes: cigarettes, e-cigarettes/vaporizers, cigarillos, pipe, cigars, chewing tobacco, nicotine patch and/or gum,
hookah/shisha, or such products in any other form.
6. In the past 10 years, have you used any drug(s) or narcotic(s) (including cannabis), or had any issues with alcohol abuse
including being advised to stop or reduce your consumption?
7. In the past 2 years, have you engaged in any high-risk activities, or do you plan to do so in the next 12 months?
Examples include: aviation (pilot or crew member), boxing, ballooning, bungee jumping, hang gliding, heli skiing/
snowboarding, motorized racing (car, motorcycle, boat, snowmobile, etc.), rock/ice climbing, scuba diving, skydiving or
other parachute jumping, or white water rafting.
Page 5 of 5
Employee Signature Date Signed
Spouse Signature Date Signed
MMM/DD/YYYY
MMM/DD/YYYY
Notice About MIB Inc.
IMPORTANT NOTICE
Your personal information will be treated as confidential. Canada Life or its reinsurer(s) may, however, make a brief report to the MIB Inc., a non-profit
membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another bureau member
company for life or health insurance or submit a claim for benefits to such a company, the bureau will upon request supply the company with the information
it may have.
Canada Life or its reinsurer(s) may also release information to other life insurance companies to whom you apply for life or health insurance, or to whom you
submit a claim for benefits. The company will not, however, reveal to another company or to the bureau the action taken on the basis of your current request
for insurance.
If you wish to see the information in your bureau file or have it corrected, please contact the bureau’s information office at:
Suite 501, 330 University Avenue, Toronto ON M5G 1R7, Tel 416.597.0590
Protecting Your Personal Information
At The Canada Life Assurance Company we recognize and respect the importance of privacy.
Your personal information:
When you apply for coverage, we establish a confidential file that contains your personal information like your name, contact information, and products and
coverage you have with us. Depending on the products or services you apply for and are provided with, this may also include financial or health information.
Your information is kept in the offices of Canada Life or the offices of an organization authorized by Canada Life. You may exercise certain rights of access and
rectification with respect to the personal information in your file by sending a request in writing to Canada Life.
Who has access to your information:
We limit access to personal information in your file to Canada Life staff or persons authorized by Canada Life who require it to perform their duties and to
persons to whom you have granted access. In order to assist in fulfilling the purposes identified below, we may use service providers located within or outside
Canada. Your personal information may also be subject to disclosure to public authorities or others authorized under applicable law within or outside Canada.
What your information is used for:
Personal information that we collect will be used for the purposes of determining your eligibility for products, services or coverage for which you apply,
providing, administering or servicing products or coverage you have with us, and for Canada Life’s and its affiliates’ internal data management and analytics
purposes. This may include investigating and assessing claims, paying benefits, and creating and maintaining records concerning our relationship.The consent
given in this form will be valid until we receive written notice that you have withdrawn it, subject to legal and contractual restrictions. For example, if you withdraw
your consent, we may not be able to continue to adjudicate or administer a claim for benefits.
If you want to know more:
For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service
providers), write to Canada Life’s Chief Compliance Officer or refer to www.canadalife.com.
Authorization and Declarations
I authorize:
• Canada Life, any healthcare provider, my plan administrator, other insurance companies or reinsurance companies, the MIB Inc., administrators of
government benefits or other benefits programs, other organizations, or service providers working with Canada Life to exchange personal information,
when necessary to determine my insurability and to administer the group benefits plan;
• Canada Life to have performed tests, examinations, blood profiles and urinalysis tests as may be required to determine my insurability in connection with
this application;
• Canada Life to release my medical records to the regular healthcare provider or clinic named in this application including any test results that may be
obtained during the application process;
• Canada Life to communicate with me about this application, with electronic messages, using either the mobile number or the email address I have provided;
• My plan sponsor to deduct from my pay and remit to Canada Life the plan member contributions required under the plan, if applicable.
I certify or confirm that:
• I am actively at work on the date this application is signed;
• I have read and agree with the Important Notice describing the procedures of the MIB Inc.;
• I have retained a copy of this application;
• If applying for coverage for dependents, I am authorized to act on their behalf;
• A photocopy or an electronic copy of this authorization is as valid as the original.
The statements and answers on this form will be used to determine your insurability and to provide benefits under the plan. Any changes in the accuracy of any
of the statements and answers on the form between the date this form is signed and the effective date of any coverage approved by Canada Life must be reported
to Canada Life. I understand that if I fail to do so, any coverage granted may be void.
I declare that to the best of my knowledge, all of the above answers to the questions are complete and true. I understand that if any answer is incomplete
or false, any coverage granted may be void. I understand that I may be refused for coverage for all or part of any benefit if, in the opinion of Canada Life,
I am not insurable for all or part of that benefit.
For Quebec Applicants: I request that all communication and documents be in English.
Je demande à ce que toutes les communications et tous les documents soient en anglais.
Mailing Address
The Canada Life Assurance Company
Group Medical Underwriting
PO Box 6000
Winnipeg MB R3C 3A5
Email: groupmed@canadalife.com
Telecommunications Relay Service: 1.800.855.0511
(available for the hearing impaired)
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Form 1: Employees information (completed by plan administrator) (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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