Name of employee Policy Number
Division Number Certificate Number Date returned to work
Date Name of Group
By (Employer or Administrator)
Name of employee Policy Number
Division Number Certificate Number Date returned to work
Date Name of Group
By (Employer or Administrator)
M403-1/20
© 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.
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M403-1/20
© 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.
NOTICE OF RETURN TO WORK
NOTICE OF RETURN TO WORK
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