Division number: Plan member ID:
Plan sponsor:
Plan member name (print):
last name first name middle initial
Please print clearly, in INK.
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
For CL Head Office Use Only
CL Certificate Number
Please print clearly and complete this form in INK. Plan Member should return the completed form to your Plan Administrator. If you use GroupNet for Plan Admin,
completed form should be maintained by the Plan Administrator.
1. General enrolment
Trustee appointment
You may wish to appoint a trustee/
administrator by completing this
The original of this form will be
required for a life claim.
If designating a beneficiary who is a minor or who lacks legal capacity you may wish to appoint a trustee/administrator by
completing this form. This appointment may not be suitable for all purposes.
If you are designating a trustee/administrator, we recommend you consult with a legal advisor, and with any proposed
Do not complete this section if you have made another trustee/administrator appointment.
I hereby appoint the following trustee to receive and to hold in trust, on behalf of any beneficiary, money payable to the
beneficiary under this group benefits plan where, at the time payment is to be made, the beneficiary is a minor or otherwise
lacks legal capacity. Any such payment, to its extent, will release The Canada Life Assurance Company from further liability.
The trustee shall act prudently and may use the money, including any returns on it or investments made, for the education
and/or maintenance of the beneficiary. The trust will terminate once the beneficiary is of the age of majority and has legal
capacity. At that time, the trustee shall deliver to the beneficiary all assets held in trust.
3. Privacy
This section explains Canada Life’s
commitment to privacy.
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.
4. Authorizations and
This section must be signed and
dated in INK by the plan member.
I have read and understand and agree with the contents of the section on this form entitled “Privacy”.
I authorize:
Canada Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators
of government benefits or other benefits programs, other organizations, or service providers working with Canada Life
or the above to exchange personal information, when relevant and necessary to determine my eligibility for coverage
and to administer the plan.
I agree that a photocopy or electronic copy of the Authorizations and Declarations section is as valid as the original.
I certify that the information given is true, correct and complete to the best of my knowledge.
www.canadalife.com 1-800-957-9777
M6242-1/20 © 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.
Plan number:
Plan member signature:
Trustee last name first name middle initial Relationship to plan member