Name of deceased
Date of birth Date of death Cause of death
Plan name Group Life policy number Plan member ID number
When proceeds are payable to the estate, please include social insurance number
Claimant’s name Relationship to the deceased
Phone number Claimant’s date of birth
Social insurance number, security number or taxpayer account number
n n n n
n , please specify
Page 1 of 2
Claimant signature Date
Claimant’s name (please print) Witness signature
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GROUP LIFE CLAIMANT STATEMENT
Plan member Dependent
Claimant’s basis of claim (check one)
Named beneciary Beneciary’s guardian/legal tutor or curator Estate’s legal representative Trustee
The life insurance proceeds are non-taxable. Please advise how you wish to receive these proceeds:
I have chosen a lump sum payment of these proceeds.
Please arrange for a nancial advisor to visit and discuss my options. The best time to call me is
For Paid Up life insurance claims or terminated plans, proceeds are paid as a lump sum only.
Protecting your Privacy
We take your privacy seriously. We keep all your personal information in a condential le in our ofces, or the ofces of an organization we’ve
authorized. The only person with access to the information are: people working at Canada Life and those we’ve authorized, who need the
information to do their jobs and manage your claim, those whom you’ve given access, those authorized by law both within Canada and in any other
jurisdiction where your personal information is held. For a copy of our Privacy Guideline see canadalife.com or you can write to Canada Life’s Chief
Authorizations and Declarations
I authorize Canada Life, any healthcare provider, the plan administrator, other insurance or reinsurance companies, administrators of government
benets or other benets programs, other organizations or service providers working with Canada Life or working with the deceased’s plan administrator,
within or outside Canada, to exchange personal information, when necessary to investigate and assess my claim, to administer the group benets plan
and to audit the assessment of the claim. I further authorize the use of my social insurance number for income tax reporting. I also consent to the use of
my personal information for Canada Life and its afliates’ internal data management and analytics purposes
I have provided the information on this form in order to obtain payment of Group Life proceeds payable to me (in a personal capacity or on behalf of a
beneciary) and I hereby declare that I am legally entitled to receive all or a share of the proceeds payable under the Group Life Policy. I certify that by
making payment to me, Canada Life has met its obligation to me. By signing below, I conrm that: I have read, understand and agree with the contents
of this form and authorize Canada Life to collect, use, and disclose my personal information, all statements I have made about my claim are true and
complete, my authorization is valid until I cancel it in writing, and a photocopy or electronic copy of this authorization is as valid as the original.