210(2018/02/09) 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
GROUP LIFE & DEPENDENT LIFE CLAIM - STATEMENT OF EMPLOYER
To be completed by the employer or plan administrator.
Employee Data
Member’s last name: First name: Date of birth:
mm/dd/yyyy
Address:
Street number and name
City: Province: Postal Code:
Policy number: Certificate number:
Group Life Claim
Member’s last name: First name: Date of birth:
mm/dd/yyyy
Address:
Street number and name
City: Province: Postal Code:
Date employment commenced:
mm/dd/yyyy
Date last worked prior to death:
mm/dd/yyyy
If not actively at work at death, state reason: Sick leave
Retired
Other (specify)
Date of absence:
Current Salary*: $ Date of death:
mm/dd/yyyy
Cause of death: Accident (Further details may be required)
Other (specify)
Unknown at present
* Please note: As outlined in your Group Policy, if the current salary differs from the amount on your last billing statement, we will consider the lesser of the current salary
and the billed amount.
Group Dependent Life Claim
Deceased’s last name: First name: Date of birth:
mm/dd/yyyy
Address:
Street number and name
City: Province: Postal Code:
Date of death:
mm/dd/yyyy
Relationship to employee: Spouse
Common-Law Spouse
Child
Other (specify)
Dependent Life Insurance amount: $ Cause of death: Accident (Further details may be required)
Other (specify)
Employees date of hire:
mm/dd/yyyy
Was employee actively at work at death of dependent? Yes No
If employee was not actively at work at death, date last worked and reason:
mm/dd/yyyy
Sick leave
Retired
Other (specify)
