Print Name Signature
Date Social Insurance Number
M4437-1/20
canadalife.com • 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.
AUTHORIZATIONS AND DECLARATIONS
Protecting your Privacy
We take your privacy seriously. We keep all your personal information in a confidential file in our offices, or the offices
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: canadalife.com or you can write to Canada Life’s Chief Compliance Officer.
I have read and understand and agree with the contents of the section entitled “Protecting your Privacy” on this form.
I authorize Canada Life, any healthcare provider, the plan administrator, other insurance or reinsurance companies,
administrators of government benefits or other benefits 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 benefits 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 affiliates’ 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 beneficiary) 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 confirm 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.
INSTRUCTIONS
1. ATTACH CERTIFICATE OF ATTENDING PHYSICIAN – DISMEMBERMENT OR LOSS (FORM NO. M4442).
2. ATTACH INSURED’S ENROLLMENT CARD AND ANY CHANGES, IF YOU RETAIN THIS RECORD.
3. ATTACH ACCIDENT REPORT (IE. POLICE REPORT, EMPLOYER’S ACCIDENT REPORT).
Please return the fully completed form and supporting documents to:
The Canada Life Assurance Company
Group Life Benefits
60 Osborne St N
Winnipeg MB R3C 1V3
OR
Email: grouplifebenefits@canadalife.com
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.
