Employee’s Name
Date of Birth (YYYY/MM/DD)
Group Policy Number Certicate Number
Division Number
Employee’s Address - Street City Province Postal Code
Employee’s Phone Number
Email address
Amount of employee’s basic life insurance benet
$
Date of employment Date last worked Earnings as at last day
worked
$
Reason for leaving
Name (please enclose copies of all Application for Group Coverage and/or Group Coverage Change forms or beneciary cards
which contain beneciary information).
- please print
- please print
Name of Employer
Complete mailing address - Street City Province Postal Code Phone Number
Email address
Employer signature
- please print
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
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M7354(1)-1/20
© 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.
GROUP LIFE INSURANCE
ADVANCE PAYMENT REQUEST FORM
Instructions:
Complete this form when a terminally ill employee wishes to request an advance payment of a portion of their basic group
life insurance benefit.
Please answer all questions fully to avoid delays in processing this form. Indicate whether information does not apply, is
unavailable or is unknown.
If more space is required to answer any question, continue the answer on a separate sheet and attach it to this form.
Submit this form, together with any additional sheets, to: The Canada Life Assurance Company
Group Life Benefits 5W
60 Osborne Street N
Winnipeg MB R3C 1V3
OR
email: grouplifebenefits@canadalife.com
Fax: 204-946-8783
Section 1 EMPLOYER INFORMATION
To be completed by employer
Section 2 EMPLOYEE INFORMATION
To be completed by employer
Section 3 BENEFICIARY INFORMATION
To be completed by employer
Does the record indicate any beneciary(ies) designated as irrevocable? Yes No
Fax Number
Date
WITNESS NAME (please print) INSURED NAME (please print)
WITNESS SIGNATURE INSURED SIGNATURE
- please print
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© 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.
EMPLOYEE’S REQUEST AND RELEASE
To be completed by employee
NOTE: An employee is eligible to request an advance payment of up to 50% of the employee’s total basic group life insurance benefit
or $50,000, whichever is less.
To be eligible for an advance payment, you must be suffering from a terminal illness and have a life expectancy of 24 months or less.
I certify that I am employed by , and have basic life insurance coverage under
Group Policy No. (the “Policy”) issued to (the “Policyholder”) by
The Canada Life Assurance Company; and
WHEREAS I am presently disabled and have been diagnosed as terminally ill; and
WHEREAS pursuant to the terms of the Policy, a basic life insurance benefit of $ is payable on my death; and
WHEREAS I hereby request that an immediate advance payment of my basic life insurance benefit be made to me in the amount of the
lesser of 50% of my basic life insurance benefit and $50,000, which would otherwise be payable to my beneficiary(ies) or, in the absence
of any beneficiary(ies), to my estate (the “Advance Payment”); and
WHEREAS I understand that the Advance Payment is not owing under the Policy and would be advanced by Canada Life on the basis
of compassionate grounds; and
WHEREAS I have agreed that interest at a rate equal to Canada Life’s standard 1 year rate +2 percent per annum would be payable
and would accrue with respect to the Advance Payment, from the date of the said Advance Payment to the date of my death, and that
such interest would be simple interest and not compounded; and
WHEREAS I understand and agree that, if an Advance Payment is made, Canada Life shall, at my death and subject to the condition
that my basic group life insurance coverage under the Policy is in effect at the date of my death, pay to my beneficiary(ies), or in the
absence of any beneficiary(ies), to my estate, an amount equal to the basic life insurance benefit payable under the Policy at my death
less the Advance Payment and accrued interest; and
WHEREAS I understand and agree that should my basic life insurance coverage under the Policy terminate prior to the date of my
death and after receiving the Advance Payment, Canada Life may require me to pay back the Advance Payment together with interest
accrued to the date of repayment.
WHEREAS I understand and agree that I will be solely responsible for any income tax liability which may occur as a result of the Advance
Payment; and
NOW THEREFORE in consideration of Canada Life providing me with the Advance Payment, and for other good and valuable
consideration, the receipt and sufficiency of which is hereby acknowledge, I, , do hereby
remise, release, acquit and forever discharge The Canada Life Assurance Company and the Policyholder from any and all claims, debts,
demands, actions or causes of actions which I, my heirs, administrators, executors, assigns or beneficiaries ever had, have or may have
with respect to or in connection with the Advance Payment, and the interest accrued on the Advance Payment, which would otherwise
be payable at my death under the Policy.
The preamble of this Request and Release is an integral part of this Request and Release and is not a mere recital.
I, represent, warrant and certify that in executing this Request and Release, I do so with full
knowledge of any and all rights which I may have under or in connection with the Policy.
IN WITNESS WHEREOF, I, , have hereunto set my hand and seal
this day of , 20 .
SIGNED, SEALED AND DELIVERED
In the Presence of:
Date Signature
M7354(1)-1/20
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© 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.
PROTECTING YOUR PERSONAL INFORMATION
We take your privacy seriously. We keep all your personal information in a confidential file in our offices, or the office 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 personal information is held. For a copy of our Privacy Guideline see canadalife.com or you
can write to Canada Life’s Chief Compliance Officer.
EMPLOYEE’S STATEMENT
To be completed by employee
To be eligible for an advance payment of your basic group life insurance, you must be suffering from a terminal illness and have a
life expectancy of 24 months or less. After you have signed this statement below, your physician should complete the Attending
Physician’s Statement on the next page.
I expressly consent, authorize and direct any physician, surgeon or any other person who has examined me, and every hospital or other
institution where I have received treatment to exchange with The Canada Life Assurance Company or its duly authorized representatives
any knowledge or information required for the purposes of assessing my request for an advance payment of my basic group life
insurance. A photocopy of this authorization shall be as valid as the original.
Return completed form to: The Canada Life Assurance Company
Group Life Benefits 5W
60 Osborne Street N
Winnipeg MB R3C 1V3
OR
email: grouplifebenefits@canadalife.com
Fax: 204-946-8783
Date Signature
© 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.
Physician Name Telephone Number
Address Email Address
Name of Insured
Address: Street City Province Postal Code Group Policy Number
Diagnosis:
What stage of cancer?
If yes, provide details:
Future Prognosis:
Life expectancy (survival rate):
Please provide a description of the Insured’s medical condition, including any complications, in the space provided below and attach
medical evidence to support the diagnosis. (to be completed by a SPECIALIST physician if being followed by a specialist).
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canadalife.com • 1-855-812-4211
ATTENDING PHYSICIAN’S STATEMENT
ADVANCE PAYMENT REQUEST
Return completed form to: The Canada Life Assurance Company
Group Life Benefits 5W
60 Osborne Street N
Winnipeg MB R3C 1V3
OR
email: grouplifebenefits@canadalife.com
Fax: 204-946-8783
The above named Insured has requested an advance payment of their Life Insurance proceeds due to a terminal illness. In order to
provide consideration to the Insured’s request, we require the following information:
If cancer, is it metastatic? Yes No
Is the Insured undergoing any treatment? Yes No
Do you consider the Insured to be mentally competent/mentally able? Yes No
I certify the above information to be true and correct.
, M.D.
Clear