(please print)
Policy number:
Policyowner’s name:
Last First Middle
Name of Canadian nancial institution (Bank, Trust Co., etc.):
Transit number: Institution number:
Account number:
Signature of Policyowner(s):
X
Date:
Signature of Policyowner(s):
X
Date:
Page 1 of 2
M7269-9/19
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
INDIVIDUAL HEALTH
DIRECT DEPOSIT AUTHORIZATION
Savings account (consult your institution for the proper ID number)
Chequing account (attach sample cheque marked “void”)
Notice regarding personal information
Further to an application for any product or services, Canada Life establishes a confidential file that contains personal information
concerning you. The file is kept in the office of Canada Life or of third-parties acting on our behalf. Rights of access to personal
information in the file are limited to our staff or persons authorized by us (e.g. service providers), whether located in Canada or
elsewhere who require it to perform their duties, to you and persons authorized by you, and, as personal information may be
collected, used, or disclosed in or from Canada or elsewhere, access may also be had by persons authorized by the laws of Canada
or elsewhere as applicable. Your rights of access and correction of any inaccuracies may be exercised by writing to The Ombudsman,
The Canada Life Assurance Company, 255 Dufferin Avenue, London ON N6A 4K1. We collect, use and disclose your personal
information to: (1) process this application and, if this application is approved, provide and service the financial product(s) and/or
service(s) applied for, (2) advise you by telephone or otherwise of products and services to help you plan for financial security,
(3) respond to, investigate and process claims, (4) create and maintain records concerning our relationship as appropriate, and (5)
fulfill such other purposes as are directly related to the preceding.
Note: In accordance with legal requirements, a copy of the entire application, including personal information, may be included with
the policy as delivered or be provided separately to the owner. For a copy of our Privacy Guidelines or questions about our personal
information policies and practices (including with respect to service providers), write to Canada Life’s Chief Compliance Officer or
refer to www.canadalife.com.
Authorizations and Declarations
I/We authorize Canada Life to deposit all claim payments directly to the account indicated above, and to exchange my/our personal
information with my financial institution when necessary for this purpose. I/We understand that this authorization will remain in effect
until revoked by me/us in writing. A photocopy or electronic copy of this authorization is as valid as the original.
I/We certify that the information given is true, correct and complete to the best of my/our knowledge.
For Québec applicants:
I request that this form be in English.
Je demande que ce formulaire me soit remis en anglais.
(We require your signature(s) in order to process your request for Direct Deposit.)
