Fillable GROUP LIFE CLAIM CLAIMANTS STATEMENT (Equitable Life of Canada)

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GROUP LIFE CLAIM CLAIMANTS STATEMENT (Equitable Life of Canada)

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684(2020/06/30) Page 1 of 2
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.668.4095 T 519.886.5210
www.equitable.ca
GROUP LIFE CLAIM – CLAIMANT’S STATEMENT
Instructions
1. If the policy is payable to a named beneficiary or beneficiaries:
a) This statement should be completed by the named beneficiary, unless a minor.
b) If there is more than one beneficiary, each beneficiary should complete a seperate Claimant’s Statement.
c)
If any named beneficiary is a minor, this statement should be completed, on behalf of the minor beneficiary,
by the named trustee.
d)
If a trustee was not named for a minor beneficiary, by the guardian or other person authorized by law to deal with the minor’s
property. A certified copy of the Letters of Guardianship must be submitted.
2. If the policy is payable to the Estate the cheque will be payable to “The Estate”.
Limitation Period
A limitiation period provision describes the time period in which you may commence a proceeding for recovery of policy benefits.
This time period is set out in provincial insurance legislation or other legislation that applies to your claim.
Information about the claimant
Claimant’s last name: First name:
Address: City: Province: Postal Code:
Street number and name
Telephone number: Date of birth: Relationship to deceased:
Claimant’s basis of claim: Named beneficiary Trustee Beneficiary’s Guardian
Estate Representative Other, please specify:
Information about the deceased
Is the deceased the: Member Spouse Dependent Policy number:
Deceased’s last name: First name:
Address: Apartment or suite:
Street number and name
City: Province: Postal Code:
Social Insurance Number: Date of birth: Marital status at death:
mm/dd/yyyy
Cause of death (specific): Relationship to member (if not member):
Place of death: Date of death:
mm/dd/yyyy
Name Address Date Reason
Names and addresses of all Physicians who attended the deceased in past 2 years
684(2020/06/30) Page 2 of 2
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
GROUP LIFE CLAIM – CLAIMANT’S STATEMENT
Name Address Date Reason
Authorization & Acknowledgement
I certify that the information given on this form is true, correct and complete.
For the purposes of underwriting, administration, claims processing and adjudication with respect to the Group Policy and any
supplementary forms/documents, I authorize The Equitable Life Insurance Company of Canada (“Equitable”), its employees,
representatives and service providers to use my personal information, and exchange such personal information with reinsurers, insurers,
investigative agencies, health care providers and facilities, and any other person or party whom I authorize.
For the above purposes, I authorize any physician, practitioner or other health care provider, hospital, clinic or other medical facility,
pharmacy, insurer, employer (past and present), WSIB/CNESST Workers Compensation plan, medical or benefit payment plan, service
provider, and any other institution, person or party that has any record or knowledge of the deceased’s death, to give to Equitable full
particulars of such information, including any prior medical history and benefits.
I authorize and direct the Equitable Life Insurance Company of Canada to deduct from the life insurance proceeds payable to me any
overpayment of disability benefits paid to the deceased by Equitable Life.
A photocopy of this acknowledgement shall be as valid as the original.
Signature of Witness:
Claimant’s signature:
Name of Witness:
Location signed (city): Location signed (province): Date:
mm/dd/yyyy
Address:
Street number and name
City: Province:
Apartment or suite:
Postal Code:
Telephone number (home): Telephone number (office):
Fax this completed form, along with any other pertinent documentation to 1.888.505.4373
or mail to (do not use staples):
Equitable Life of Canada
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn Waterloo, Waterloo Ontario N2J 4C7
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GROUP LIFE CLAIM CLAIMANTS STATEMENT (Equitable Life of Canada)

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Completed 1 March 2021

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