Page 1 of 2
Please complete both pages of this form.
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.
Group Benefits
Application for Optional Life Insurance for Plan Member and Dependants
The Manufacturers Life Insurance Company GL0005E (03/2006)
INSTRUCTIONS - Please print all answers
1.
PLAN MEMBER ONLY PLAN MEMBER, SPOUSE AND DEPENDANTSPLAN MEMBER AND SPOUSE
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 (GL0004E). (Evidence of Insurability is NOT
required if changing status from "Smoker" to "Non-smoker".)
2.
Please ensure that ALL SECTIONS are completed.
Section 1 - Plan sponsor's information - TO BE COMPLETED FIRST BY PLAN ADMINISTRATOR.
Sections 2, 3, 4, 5 and 6 - Plan member's information - To be completed by plan member and submitted to Manulife Financial.
SPOUSE AND/OR DEPENDANTS
1
Plan contract number(s) Plan member certificate numberDivision number
Class
Plan sponsor's
information
Plan sponsor
2
Province of residence
Plan member's name (last, first and middle initial)
Language preference/Langue préférée
French/Français
English/Anglais
Sex
Female
Plan member's
information
Male
Date of birth (dd/mmm/yyyy)
Eligibility date (dd/mmm/yyyy)
Annual earnings
$
Plan member's present amount of optional life
Additional amount requested
Total amount requested
Optional life amount:
OR
x salary
ORunits of
$$ $
=
$
x salary OR ORunits of
$$ $
=
$
OR
x salary ORunits of
$$ $
=
$
Spouse's present amount of optional life
Additional amount requested
Total amount requested
Spousal optional life amount:
OR x salary ORunits of
$$ $
=
$
x salary OR ORunits of
$$ $
=
$
OR
x salary ORunits of
$$ $
=
$
Plan administrator name Date signed (dd/mmm/yyyy)
Phone number
Email address
Have you smoked (cigarettes, cigars, pipe, etc.) or used tobacco in any other form within the last 12 months?
NoYes
Dependant's present amount of optional life
Additional amount requested
Total amount requested
Dependant optional life amount:
OR
units of
$$
OR units of
$$
OR
units of
$$
50231
010
Saint Mary's University
Dependant coverage
Dependant's name (last, first and middle initial)
Note: you will be the
beneficiary of your dependant's
insurance, if you are then
living, otherwise the beneficiary
will be your estate.
Student status full time student
No
Yes
Relationship to plan member
5
Certification and
authorization
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.
6 Plan member's
information
Date of birth (dd/mmm/yyyy)
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.
Page 2 of 2The Manufacturers Life Insurance Company GL0005E (03/2006)
Spousal coverage
Spouse's name (last, first and middle initial)
Sex
Female
Male
Note: you will be the
beneficiary of your spouse's
insurance, if you are then
living, otherwise the beneficiary
will be your estate.
Has your spouse smoked (cigarettes, cigars, pipe, etc.) or used tobacco in any other form within the last 12 months?
NoYes
4
Date of birth (dd/mmm/yyyy)
Plan member's signature Date (dd/mmm/yyyy)
Name of beneficiary (last, first and middle initial)
Relationship to plan memberAdditional name, if applicable (last, first and middle initial)
Beneficiary designation
information
Relationship to plan member
Relationship to plan memberAdditional name, if applicable (last, first and middle initial)
If a beneficiary is not assigned,
"ESTATE" will be assumed.
3
If spouse is beneficiary, designation is:
IrrevocableRevocable
Irrevocability
For Quebec residents only
In Quebec, the designation of your spouse as
beneficiary is irrevocable unless otherwise specified.
Note: If 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.
For designated beneficiaries
under the age 18.
I appoint ____________________________________________________________________ as Trustee to receive any amount due
to any beneficiary under the age of 18.
Mailing instructions7
Please send the completed form to:
Group Medical Underwriting
Manulife Financial
PO BOX 2026
HALIFAX NS B3J 2Z1
Signature of spouse (required only if evidence regarding insurability of spouse is provided in this form) Date (dd/mmm/yyyy)
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