Name of deceased
Date of Birth Date of Death
Plan name
Group Policy Number Certicate Number Division Number Benet Class
$
$
$
$
Occupation Employment Start Date
Last date worked Reason for leaving work
Salary or wages at last day worked
Signature and title Date
Print name Email address
Mailing address Phone number
•
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
GROUP LIFE PLAN SPONSOR STATEMENT
Instructions • Plan Sponsor submits the Application for Group Coverage, along with any benefit change requests that have been retained.
• Claimant completes and submits the Group Life Claimant Statement.
Plan member Dependent
Benet Claimed: Life
Accidental Death
Supplemental / Optional Life
Survivor Income Benet
If the deceased is the plan member, please provide the following information:
Please return the fully completed form to:
The Canada Life Assurance Company
Group Life Benets
60 Osborne St N
Winnipeg MB R3C 1V3
Or
Email: grouplifebenets@canadalife.com
Fax: 204-946-8783
Who should complete the Group Life Claimant Statement
Proceeds payable to:
Adult beneciary
Beneciary who is a
minor or who lacks legal
capacity, located in
Quebec
Beneciary who is a
minor or who lacks legal
capacity, located outside
Quebec
Claimant unable to handle
nancial affairs
Estate
Estate in Quebec with
no will
1 or 2 2 or 3 or 4 2 or 4 5 6 7
1. Beneciary
2. Trustee (copies of trust documents required)
3. Legal tutor or curator (copies of judgment required)
4. Court appointed guardian of the beneciary’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
Supplemental
Life
Basic and
Supplemental
Life exceeding
$100,000 in
Quebec
Basic and
Supplemental
Life outside of
North America
Optional Life
Accidental
Death
Survivor Income
Benet
Paid Up
Insurance
proceeds
payable to
the estate
exceeding
$100,000 in
Quebec
Insurance
proceeds
payable to
the estate
exceeding
$100,000
outside Quebec
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
13
1. Death certicate or funeral director’s statement of death
2. Attending Physician’s Certicate (M63)
3. Police report or workplace accident report
4. Medical Examiner’s Report, Coroner’s Report or Autopsy Report
5. Marriage certicate or sworn afdavit to conrm common law status
6. Birth certicate for all eligible survivors
7. Canada/Quebec Pension Plan statement of survivor benets,
if applicable
8.Original certicate of insurance, if available
9. Act of Death (long form) issued by the Quebec Registrar of Civil Status
10. Will search certicate 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 certicate of appointment of Estate Trustee or
Letter of administration
14. Original death certicate or certied true copy of the death certicate by a
notary public
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M62(PS)-1/20
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Any modification of this document without the express written consent of Canada Life is strictly prohibited.
