Fillable M6190 GROUP COVERAGE CHANGE FORM

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M6190 GROUP COVERAGE CHANGE FORM

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• Page 1 of 3
Plan number: Division number: Plan member ID:
Plan sponsor:
Plan member name (print):
last name first name middle initial
Plan member returned to work on: Month Day Year
Reason for reinstatement (E.g., return from leave of absence, return from lay-off)
n n
n
n
Spousal insurer’s name:
Plan number:
Effective date of loss of coverage through spousal plan: Month
Day Year
n n
Effective date of change: Month Day Year
n n
n n n n Month Day Year
n
Middle Date of birth
Last name First name Initial mm/dd/yy
n n
n n n
n n
n n n n n n n n n n n n
n n
n n
n n n
n
n
n n
n n
n n n
n
n
n n
n n
n n n
n
n
n n
n n
n n n
n
n
CONTINUED ON NEXT PAGE
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
www.canadalife.com 1-800-957-9777
M6190-1/20 © 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.
GROUP COVERAGE CHANGE FORM
For Canada Life Head Office Use Only
Canada Life
Certificate Number
Please print clearly and complete both sides of this form, in INK. Sections 1 & 2 are to be completed by the plan administrator and sections 3 through 13 are to
be completed by the plan member, for applicable changes. The plan administrator should keep a copy of the completed form for their records and send the
original to The Canada Life Assurance Company. For self-administered plans and GroupNet clients who maintain their own plan member’s records the plan administrator
should attach this form to the plan member’s application.
1. General enrolment
information
2. Reinstatement
This information will be used to
re-enrol the plan member in the
group benefits plan.
3. Refusal of benefits
Note: Health and/or dental coverage can only be refused if you and/or your dependants are covered by duplicate group benefits
through your spouse’s employer.
I understand the plan of group benefits offered to me, but I decline to participate in:
Healthcare for
myself and my dependants my dependants only
Dentalcare for myself and my dependants my dependants only
If you lose spousal coverage you must apply for coverage within 31 days of loss of such coverage. If you do not apply within
31 days you and your dependants may be required to provide proof of insurability acceptable to Canada Life to be covered.
If you are approved, coverage for dental benefits may be limited.
Please see your plan administrator for details.
4. Addition of group
health and/or dental
benefits
You may apply to be enrolled for group coverage if your spouse has lost group benefits coverage through their employer.
Indicate the benefit(s) no longer covered under the spousal plan: Healthcare Dentalcare
5. Dependant information change
This section must be completed if you are adding or deleting a dependant, or updating dependant information.
If there are more than four dependants, please attach a separate list. Please print clearly, in INK.
To: Single coverage Family coverage
Reason: Birth of child Divorce Marriage Cohabitation – Date of marriage/cohabitation:
Other (please specify)
Spouse Information
Add Change Delete
Gender
Male
Female
Undisclosed
Other
What group benefits coverage does your spouse have through their employer?
Where applicable, benefit payments will be coordinated between this plan and your spouse’s plan.
HEALTHCARE
Single Family Waived None
DENTALCARE
Single Family Waived None
VISIONCARE
Single Family Waived None
Dependant Information
Last name First name
Middle
Initial
Date of birth
mm/dd/yy Gender
Full time
student
Disabled
dependant
Add Change Delete
Male
Female
Undisclosed
Other
Add Change Delete
Male
Female
Undisclosed
Other
Add Change Delete
Male
Female
Undisclosed
Other
Add Change Delete
Male
Female
Undisclosed
Other
Please print clearly in INK.
From: To:
last name first name middle initial last name first name middle initial
last name first name middle initial
last name first name middle initial
last name first name middle initial
n
n
last name first name middle initial
last name first name middle initial
last name first name middle initial
n
n
n
Please print clearly, in INK.
Trustee last name first name middle initial Relationship to plan member
From: To:
last name first name middle initial last name first name middle initial
Relationship to plan member:
n
Effective date: Month Day Year
CONTINUED ON NEXT PAGE
Page 2 of 3
6. Plan member name
change
7. Beneficiary designation
This section must be completed to
designate a beneficiary for your life
benefits, if applicable.
The original of this form will be
required for a life claim.
Crossed out beneficiary
designations must be initialed.
I hereby revoke all previous beneficiary designations and designate the following as beneficiary(ies).
Primary Beneficiary
Percent
allocated
Relationship
to plan member
To be divided as follows: As per the percentage indicated above, or
In equal shares to the survivor(s)
8. Contingent beneficiary
designation
If you wish to appoint a contingent
beneficiary in the event that
there are no surviving primary
beneficiaries at the time of your
death, please complete this
section.
If there are no surviving benficiaries at the time of my death, I declare that the following Contingent Beneficiaries shall
receive the proceeds. If there are no surviving Contingent Beneficiaries at the time of my death, the proceeds shall be paid
to my estate.
Contingent Beneficiary
Percent
allocated
Relationship
to plan member
To be divided as follows: As per the percentage indicated above, or
In equal shares to the survivor(s)
You may change this beneficiary designation at any time upon notice to Canada Life. If you wish to make the beneficiary
designation irrevocable (meaning you may not change the designation or make certain changes to your coverage under
the plan without the written consent of the beneficiary) please complete form #M6348 BIL.
Note: Where Quebec law applies and you have designated your married spouse or civil union spouse as beneficiary,
the designation will be irrevocable unless you check the box marked “Revocable”, below.
I hereby make the above beneficiary designation:
Revocable, I may change this beneficiary designation at any time
For Quebec Applicants Only - Benefits payable under this plan to a beneficiary who, at the time payment is to be made, is
a minor or lacks legal capacity, will be paid to their tutor(s) or curator(s), unless a valid trust has been established for the
benefit of the beneficiary, by Will or by separate contract, to receive any such payment and Canada Life has been provided
notice of the trust. If a valid trust has already been established, designate the trust as the beneficiary in this section.
Before designating a trust, you should seek legal advice.
9. Trustee appointment
You may wish to appoint a trustee/
administrator by completing this
section
The original of this form will be
required for a life claim.
DO NOT COMPLETE THIS SECTION IF YOU ARE A QUEBEC RESIDENT
If designating a beneficiary who is a minor or who lacks legal capacity you may wish to appoint a trustee/administrator by
completing this form. This appointment may not be suitable for all purposes.
If you are designating a trustee/administrator, we recommend you consult with a legal advisor, and with any proposed
trustee/administrator.
Do not complete this section if you have made another trustee/administrator appointment.
I hereby appoint the following trustee to receive and to hold in trust, on behalf of any beneficiary, money payable to the
beneficiary under this group benefits plan where, at the time payment is to be made, the beneficiary is a minor or otherwise
lacks legal capacity. Any such payment, to its extent, will release The Canada Life Assurance Company from further liability.
The trustee shall act prudently and may use the money, including any returns on it or investments made, for the education
and/or maintenance of the beneficiary. The trust will terminate once the beneficiary is of the age of majority and has legal
capacity. At that time, the trustee shall deliver to the beneficiary all assets held in trust.
10. Current beneficiary
name change
Complete if a current beneficiary
has had a legal change of name
11. Opting Out of all Group
Benefits
You may opt out of your group
benefits plan, if your coverage is
non-compulsory.
Opting out of all group benefits - for non-compulsory plans only.
I understand the group benefits plan offered to me, but I decline to participate.
If at any time in the future you wish to join the group benefits plan, you and your dependants will have to provide proof of
insurability acceptable to Canada Life to be covered. If approved, dental benefits, if applicable, may be limited.
Please see your plan administrator for details.
Plan administrator signature:
Date:
Plan member signature: Date:
Page 3 of 3
12. Privacy
This section explains Canada Life’s
commitment to privacy.
At The Canada Life Assurance Company we recognize and respect the importance of privacy.
Your personal information:
When you apply for coverage, we establish a confidential file that contains your personal information like your name,
contact information, and products and coverage you have with us. Depending on the products or services you apply for and
are provided with, this may also include financial or health information. Your information is kept in the offices of
Canada Life or the offices of an organization authorized by Canada Life. You may exercise certain rights of access and
rectification with respect to the personal information in your file by sending a request in writing to Canada Life.
Who has access to your information:
We limit access to personal information in your file to Canada Life staff or persons authorized by Canada Life who require it
to perform their duties and to persons to whom you have granted access. In order to assist in fulfilling the purposes
identified below, we may use service providers located within or outside Canada. Your personal information may also be
subject to disclosure to public authorities or others authorized under applicable law within or outside Canada.
What your information is used for:
Personal information that we collect will be used for the purposes of determining your eligibility for products, services or
coverage for which you apply, providing, administering or servicing products or coverage you have with us, and for
Canada Life’s and its affiliates’ internal data management and analytics purposes. This may include investigating and
assessing claims, paying benefits, and creating and maintaining records concerning our relationship.The consent given in this
form will be valid until we receive written notice that you have withdrawn it, subject to legal and contractual restrictions. For
example, if you withdraw your consent, we may not be able to continue to adjudicate or administer a claim for benefits.
If you want to know more:
For a copy of our Privacy Guidelines, or if you have 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.
13. Authorizations and
declarations
This section must be signed and
dated in INK by the plan member.
I hereby apply for coverage under the group benefits plan issued by Canada Life.
I have read and understand and agree with the contents of the section on this form entitled “Privacy”.
I authorize:
• my plan sponsor to deduct from my pay and remit to Canada Life the plan member contributions required under the
plan, if applicable;
• Canada Life to use my social insurance number for tax reporting purposes and as an identification number where it is
required in the administration of the plan;
• Canada Life, any healthcare provider, my plan administrator, other insurance or reinsurance companies, administrators
of government benefits or other benefits programs, other organizations, or service providers working with Canada Life
or the above to exchange personal information, when relevant and necessary to determine my eligibility for coverage
and to administer the plan.
If applying for coverage for my spouse and/or dependants, I confirm that I am authorized to act on their behalf.
I agree that a photocopy or electronic copy of the Authorizations and Declarations section is as valid as the original.
I certify that the information given is true, correct and complete to the best of my knowledge.
For Quebec applicants: I request that this form be in English.
Je demande que ce formulaire me soit remis en anglais.
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M6190 GROUP COVERAGE CHANGE FORM

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Completed 18 July 2020

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