WITNESS NAME (please print) INSURED NAME (please print)
WITNESS SIGNATURE INSURED SIGNATURE
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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
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: