Name of deceased
n n
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
This document contains both information and form fields. To read information, use the Down Arrow from a form field. 1-855-812-4211
© 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.
Deceased information
Plan member Dependent
Claimant information
Claimant’s basis of claim (check one)
Named beneciary Beneciary’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 condential le in our ofces, or the ofces 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 or you can write to Canada Life’s Chief
Compliance Ofcer.
Authorizations and Declarations
I authorize Canada Life, any healthcare provider, the plan administrator, other insurance or reinsurance companies, administrators of government
benets or other benets 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 benets 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 afliates’ 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
beneciary) 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 conrm 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.
Page 2 of 2
M62(CS)-1/20 • 1-855-812-4211
Who should complete the Group Life Claimant Statement
Proceeds payable to:
Adult beneciary
Beneciary who is a
minor or who lacks
legal capacity, located
in Quebec
Beneciary who is a
minor or who lacks
legal capacity, located
outside Quebec
Claimant unable to
handle nancial affairs
Estate in Quebec with
no will
1 or 2 2 or 3 or 4 2 or 4 5 6 7
1. Beneciary
2. Trustee (copies of trust documents required)
3. Legal tutor or curator (copies of judgment required)
4. Court appointed guardian of the beneciary’s property (copies of court
order required)
5. Claimant’s legal representative (copies of judgment required)
6. Estate’s legal representative
7. Legal heirs
Documents Required for the Group Life Claimant Statement (copies are acceptable unless indicated)
Basic and
Basic and
Life exceeding
$100,000 in
Basic and
Life outside of
North America
Optional Life
Paid Up
payable to
the estate
$100,000 in
payable to
the estate
1 or 2 9 14 2 1 or 2 and
3, 4
1 or 2 and
5, 6, 7
1 or 2 and 8 9, 10 and
11 or 12
1 or 2 and
1. Death certicate or funeral director’s statement of death
2. Attending Physician’s Certicate (M63)
3. Police report or workplace accident report
4. Medical Examiner’s Report, Coroner’s Report or Autopsy Report
5. Marriage certicate or sworn afdavit to conrm common law status
6. Birth certicate for all eligible survivors
7. Canada/Quebec Pension Plan statement of survivor benets,
if applicable
8.Original certicate of insurance, if available
9. Act of Death (long form) issued by the Quebec Registrar of Civil
10. Will search certicate from the Chambre des Notaires and The
Barreau du Quebec
11. Notarial will or holograph will with judgment/minutes
12. Declaration of legal heirs if there is no will
13. Notarized will and probate or certicate of appointment of Estate
Trustee or Letter of administration
14. Original death certicate or certied true copy of the death certicate
by a notary public
Please return the completed form and supporting documents to:
The Canada Life Assurance Company
Group Life Benets
60 Osborne St N
Winnipeg MB R3C 1V3
Email: grouplifebene
Fax: 204-946-8783
Email Communication – Important Note:
The internet is not a secure medium. If you have concerns about using email, you are encouraged to contact us by other means.