Your group plan number
Your Great-West ID number
Print your name
Your signature
Date (mm/dd/yyyy)
Telephone number
Great-West Life and the key design are trademarks of The Great-West Life Assurance Company.
Your consent
M7415-10/17
Before we can process your claim for benefits, you must read this agreement and sign in
the signature box below.
Sharing your personal information
We collect, use and disclose your personal information to:
• investigate and assess your claim
• administer your claim and the group benefits plan
• work out a rehabilitation plan to get you back to work
• audit the assessment of the claim.
We may also use your social insurance number for income tax reporting and
as an identification number if this is required in the administration of your
benefits.
We may collect and exchange your personal information
with these persons or groups when relevant and necessary
for the purpose above:
• Healthcare and rehabilitation providers
• Insurance and reinsurance companies
• Administrators of the plan, of government benefits and of other benefit
programs
• Your employer, plan sponsor and plan administrator, for the purpose of
discussing return to work planning
• Your employer’s occupational health services
• Your union representative
• Service providers and other organizations working with us, or on behalf of the
other parties mentioned above. We may use service providers outside Canada.
• An auditor authorized by us, your employer, plan sponsor or their agent
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 persons with
access to the information are:
• people working at Great-West 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 Guidelines
see greatwestlife.com or you can
write to Great-West Life’s Chief
Compliance Officer.
By signing below, you confirm that:
• You have read, understand and agree with the contents
of this form and authorize us to collect
and disclose your personal information.
• Except for audit purposes, your authorization is
valid for the duration of your claim or until you
cancel it in writing.
• All statements you have made about your claim are true
and complete
• A photocopy or electronic copy of this authorization is
as valid as the original.
© 2017 The Great-West Life Assurance Company, all rights reserved. Any modification of this
document without the express written consent of Great-West Life is strictly prohibited.
