Advisor
Telephone no. Fax no.
( ) ( )
Address Email address
Plan member’s name
Date of birth
■ ■
Month Day Year
■ ■
Spouse’s name (if eligible for spousal conversion) Date of birth
■ ■
Month Day Year
■ ■
Address Telephone no.
( )
Group policy name:
(month/day/year)
$
(month/day/year)
$
$
(month/day/year)
$
(month/day/year)
$
$
(month/day/year)
$
Date (month/day/year) Plan administrator’s name (Please print)
Telephone no.
____________
Plan administrator’s signature
( )
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Group Life Conversion Privilege Notification
Plan Member/Spouse Section
If your Canada Life group life insurance has been terminated or reduced, you may be entitled to purchase an individual life insurance conversion policy, without
providing medical evidence of insurability. The life conversion application must be received within 31 days after your group terminates or reduces, so it is important
to follow these instructions. Here’s what you need to do to convert your group life insurance:
Step 1: Provide your advisor with this completed Group Life Conversion Privilege Notification form.
If you do not have an advisor or your advisor is not licensed to sell Canada Life or Freedom 55 financial products, please visit www.canadalife.com – Contact us
An advisor will contact you and explain the life conversion options available so you can make the right choice based on your current insurance needs.
You may also speak to a customer service representative by calling:
English: 1- 800-665-0551 French: 1- 800-665-2630
The customer service representative will assist in connecting you with an advisor.
Step 2: Submit your completed application for the individual policy with the first premium in full to Canada Life or Freedom 55 Financial within 31 days after your
group insurance terminates or reduces.
Plan Administrator Section
Complete the fields below, give one copy of this form to the plan member upon termination or reduction of group life
insurance, and keep a copy for your files.
1. Group insurance policy - Financial security advisor information (if applicable)
2. Plan member/spouse information
Gender
Male
Female
Undisclosed
Other
Gender
Male
Female
Undisclosed
Other
3. Group life insurance information
Policy no.:
Reduced/terminated
amount:
Combined (max $200,000
per person) conversion
maximum
Date insurance
reduced/terminated
Plan member
Basic
Optional
Supplementary
Spouse
Basic
Optional
4. Plan administrator information
M5725-1/20
© 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.
