This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Life
Waiver
Employee’s Guide
M4811-1/20
canadalife.com • 1-855-755-6729
© 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.
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
© 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.
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
1.
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.
2.
Your Identification number must be completed. If unknown, please check with your employer.
3.
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
1.
Address:
2.
Plan number must be completed. If unknown, please check with your employer.
Claim Information
1.
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, 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
© 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.
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
© 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.
2. Names and addresses of other physicians who have treated you for this condition.
Dates:
Dates:
3. If yes, complete the following:
Dates:
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
© 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.
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
© 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.
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
© 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.
canadalife.com • 1-855-755-6729
M4811-1/20
© 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.
Clear