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Life

Waiver

Employee’s Guide

M4811-1/20

canadalife.com • 1-855-755-6729

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

Group Life Waiver of Premium Benefit

This guide contains the forms you need to apply for premium free continuance of your life insurance benefits and

some important information about the claim process.

These forms should be submitted at least 8 weeks before the end of the Elimination Period. Your notice form,

and any other correspondence you may wish to provide about your claim, should be submitted to the Canada Life

disability management services office assigned to assess your claim. Should you wish to submit your notice form

directly to Canada Life, please contact your employer for the appropriate mailing address.

1. Employee’s Statement

The Employee’s Statement asks general information about you, your job and the nature of your disability for the

purpose of assessing your claim. Please complete all questions on this form and be sure to include your Group

Plan Number.

2. Authorization Request

We need your permission to obtain information that will help us assess your claim. By signing this

authorization request, you give Canada Life permission to obtain this information from your doctor, your

employer, other insurers and hospitals where you received treatment.

3. Attending Physician’s Report

Ask your doctor to complete this form. It requests general information about your condition.

WHAT YOU SHOULD KNOW ABOUT THE CLAIM PROCESS

Employer’s Statement

Before we can assess your claim, we need a statement from your employer confirming the date your

insurance coverage began, your job duties and earnings. We have asked your employer to supply this

information directly to us.

Claim Assessment

We will assess your claim as soon as we receive these completed forms from you, your doctor and your

employer.

We will notify you promptly if you are eligible for disability benefits and explain any limitations that may apply.

Medical Information

You are responsible for providing medical proof that you are entitled to receive disability benefits. This

information must be supplied by your doctor(s) who may charge a fee for preparing it. If they do, you are

responsible for paying for it. When Canada Life requests information directly from your doctor, we will offer to

pay a correspondence fee for it.

■

■ ■

M4811-1/20

canadalife.com • 1-855-755-6729

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

Your Canada Life Employee Identification Number

NOTICE OF CLAIM

Note: If you have Guaranteed Standard Issue Program coverage with Canada Life, this form will be used as notice

of claim for that coverage as well.

Identification

Name:

Address:

Telephone:

Check the Confidential box if you authorize us to leave a message containing personal information about

your claim at that number. Otherwise, we will only leave a personal message with callback information at that

number.

confidential confidential

confidential

Enter your email address if you would like Canada Life to communicate with you by secure email about your

disability claim.

Your Identification number must be completed. If unknown, please check with your employer.

If your employer pays for all or any part of your disability benefits coverage, any benefits payable may be subject

to income tax. If this applies to you, please provide your Social Insurance Number for income tax reporting

purposes. Your Social Insurance Number may also be used as an identification number where required in the

administration of benefits.

4. Date of birth:

Employer Information

Address:

Plan number must be completed. If unknown, please check with your employer.

Claim Information

2. If disability is due to an accident, give date accident occurred:

Was the accident work-related? Yes No

If work-related, have you filed a claim with the Workers’ Compensation Board? Yes No

First Initial Last

Street & Number

City Province Postal Code

Home ( ) Work ( )

Cell ( )

Email address:

Social Insurance Number

Year Month Day

Your Employer’s Name:

Street & Number

City Province Postal Code

Telephone Number: ( )

Group Plan Number

What is the nature of your condition?

Please describe your daily routine since leaving work stating the tasks you are able to perform:

Year Month Day

Where and how did it occur?

If yes, please provide Workers’ Compensation Claim Number and contact phone number.

Year Month Day

If yes, describe

If yes, please elaborate

Grade Completed

Years completed Degree Major/Minor

Years Completed

Degree or Certificate

What is your current job title:

List all skills you have

Hobbies:

Please explain why or why not

Please explain:

Year Month Day

Wages:

Name and address of current employer

Name: Address:

M4811-1/20

canadalife.com • 1-855-755-6729

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

3. From what date has your disability continuously prevented you from performing your regular work?

4. Have you performed any other work since that date?

Yes No

5. Are you able to do any other work?

Yes No

6. Have you had this condition before?

Yes No

Education / Training / Experience

High School

Yes No

Course of Study: Academic Industrial Business Other

College Yes No

Business / Trade School Yes No

Current Job Duties

What are the normal duties in this job, and how much time do they take each week?

DUTIES HOURS PER WEEK

Do you expect to return to your regular job?

Yes No

Are you able to do some parts of your regular work? Yes No

Are you able to drive a car? Yes No Are you presently working? Yes No

Date employed:

Part-time Self-employed Full Time Trial employment

Medical Treatment

1. Name and address of the Physician currently supervising your treatment.

M4811-1/20

canadalife.com • 1-855-755-6729

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

2. Names and addresses of other physicians who have treated you for this condition.

Dates:

3. If yes, complete the following:

Dates:

Name: Address:

From To

Name: Address:

From To

Were you confined to hospital?

Hospital Name: Address:

From To

Hospital Name: Address:

From To

Your consent

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.

• manage internal data for analytics purposes

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 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 Guidelines

see canadalife.com or you can

write to Canada 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.

canadalife.com • 1-855-755-6729

M4811-1/20

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

Your group plan number Print your name Telephone number

Your Canada Life ID number Email Address

Enter your email address if you would like

Canada Life to communicate with you by secure

email about your Disability Services claim.

Your signature Date (mm/dd/yyyy)

M4811-1/20

canadalife.com • 1-855-755-6729

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

•

The patient is responsible for any fees

related to the completion of this form.

Attending Physician’s Statement - Group Life Waiver of Premium Claim

Plan Member/Employee Information and Consent: TO BE COMPLETED BY THE PATIENT

I authorize my healthcare or rehabilitation provider to disclose my personal information, including my medical and health information and including

consultation reports, to Canada Life for the purpose of investigating and assessing my claim(s), administering coverage(s) that I may have with Canada

Life and administering the group benefits plan. Medical and health information excludes genetic test results.

I acknowledge that the personal information is needed by Canada Life for the purposes stated above. I acknowledge that my consent enables

Canada Life to process my claim(s) and refusing to consent may result in delay or denial of my claim(s).

This consent may be revoked by me at any time by sending a written instruction.

I confirm that a photocopy or electronic copy of this authorization shall be as valid as the original.

Attending Physician’s Statement: TO BE COMPLETED BY THE DOCTOR

STOP

• If your patient has returned to work or is expected to return to work within 4 weeks of the Last Date Worked, complete

Page 1 only and sign the end of the form.

• For absences expected to be greater than 4 weeks, please complete Pages 1 and 2 in full.

PLEASE COMPLETE TO THE BEST OF YOUR KNOWLEDGE

If Childbirth Vaginal C-Section

Occupational Illness/injury Yes No Auto Accident Yes No

Hospitalization Is/was patient hospitalized or had day surgery

If surgery was performed please provide date and description of surgery:

Plan Member/Employee Name

(Last, First, Middle Initial) Home Phone # (+ Area Code) Cell Phone # (+ Area Code)

Address (Street, City, Province, Postal Code)

Employer’s Name Group Plan Number GWL Employee Identication Number

Height Weight Date of Birth (dd/mm/yyyy)

Last Date Worked Date Returned to Work or Expected Return to Work Date

(dd/mm/yyyy) (dd/mm/yyyy)

Plan Member/Employee Signature Date of Consent (dd/mm/yyyy)

Primary Diagnosis:

Secondary and/or Complications:

- Expected or Actual Delivery Date

(dd/mm/yyyy)

If yes, date of event:

(dd/mm/yyyy) If yes, date of event: (dd/mm/yyyy)

Date of first visit to you pertaining to this condition: First date of work absence due to condition:

(dd/mm/yyyy) (dd/mm/yyyy)

Date of admittance (dd/mm/yyyy): Date of discharge (dd/mm/yyyy): Institution Name:

Date (dd/mm/yyyy): Description:

Treatment (drug, dosage, physiotherapy, other):

Prognosis Please provide the prognosis for recovery:

■ ■

If yes, date (dd/mm/yyyy): Treatment Provider:

Please describe the patient’s symptoms including history, severity and frequency:

■ ■ ■

→

Continuation of Attending Physician’s Statement for Absences that may be Greater than 4 Weeks

Has the patient been treated for this same or similar condition in the past? Yes No

Frequency of Visits: Weekly Monthly Other

Please attach copies of all relevant:

• test results/investigations (If test results are not attached, we will interpret this as tests were not performed)

• consultation reports

• do not provide genetic test results.

If consultation report is not attached, please indicate if the patient has or will be seen by a specialist for this condition.

Is the patient following the recommended treatment program? Yes No

Notice to Physician:

The information in this statement will be kept in a life, health, or disability benefits file with the insurer or plan administrator and might be accessible

by the patient or third parties to whom access has been granted or those authorized by law. By providing the information I consent to such unedited

release of any information contained herein.

Physician’s Stamp

Name of Specialist: Specialty: Date of Visit:

Based on your clinical findings and observations, please describe the patient’s current cognitive and/or physical functional abilities.

Please list any complications and additional conditions impacting your patient’s level of function or the expected recovery period.

Prognosis Please provide the prognosis for recovery: (if not completed on page 1)

Attending Physician (please print) Certified Specialty

Address (Street, City, Province, Postal Code)

Telephone #

(+ Area Code) Fax # (+ Area Code)

Email Address

Signature Date Signed (dd/mm/yyyy)

M4811-1/20

canadalife.com • 1-855-755-6729

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

canadalife.com • 1-855-755-6729

M4811-1/20

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

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