Fillable ONGOING LONG TERM DISABILITY UPDATE 1. Information (Equitable Life of Canada)

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ONGOING LONG TERM DISABILITY UPDATE 1. Information (Equitable Life of Canada)

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  • 21 other fields

Country of origin: CANADA
File type: PDF

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Head Office
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.265.4556 T 519.886.5210
www.equitable.ca
ONGOING LONG TERM DISABILITY UPDATE
This form is to be completed by the employee. Incomplete responses or missing information will cause delays
in the assessment and handling of this file.
1. Information
Last Name:
First Name:
Group Policy No:
Date of Birth:
(dd/mm/yyyy)
Street Address:
Certificate No.:
City:
Postal Code: Phone No.:
Province:
2. Medical Information
1. Are you seeing a doctor? Yes No
2. What is this doctor’s name?
3. What was the date you last saw this doctor?
4. Please describe your present medical status.
(dd/mm/yyyy)
3. Replacement Benefits or Other Source of Income
Are you receiving income replacement benefits from any other sources? If so, please provide the date you started receiving
these benefits.
CPP (
Retirement or Disability) Yes No Date Started:
Provincial Workers Compensation Plan
Yes No Date Started:
Income Replacement Benefits – Motor Vehicle Accident
Yes No Date Started:
Pension
Yes No Date Started:
Short Term Disability, Long Term Disability,
Yes No Date Started:
Creditor Disability or other disability income
through another insurance plan.
Other
Yes No Date Started:
Are you receiving income for performing work?
Yes No
(If Yes, please indicate the work you are performing, who you are performing the work for, and the date you started working)
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
427(2020/06/30) Page 1 of 2
ONGOING LONG TERM DISABILITY UPDATE
4. Authorization & Acknowledgement:
I certify that the information given on this form is true, correct and complete. For the purposes of underwriting,
administration, claims processing and adjudication with respect to the Group Policy and any supplementary forms/
documents, I authorize The Equitable Life Insurance Company of Canada (“Equitable”), its employees, representatives
and service providers to use my personal information, and exchange such personal information with reinsurers, insurers,
investigative agencies, health care providers and facilities, and any other person or party whom I authorize. For the above
purposes, I authorize any physician, practitioner or other health care provider, hospital, clinic or other medical facility,
pharmacy, insurer, employer (past and present), provincial workers compensation plan, medical or benefit payment plan,
service provider, and any other institution, person or party that has any record or knowledge of my health relevant to this
claim, to give to Equitable full particulars of such information, including any prior medical history relevant to this claim
and benefits. I transfer and assign to Equitable, and agree to pay and refund to Equitable those disability and income
replacement benefits which I receive or are receivable from all other sources, in accordance with the provisions of the
Group Policy, including without limitation, CPP, Worker’s Compensation, and other insurance policies. A photocopy or
electronic version of this acknowledgement shall be as valid as the original.
Signature: Date:
(dd/mm/yyyy)
Upload the signed and completed form via www.equitablehealth.ca using our secure
Document Submission Tool located under the My Resources tab. You can also fax them to 1.888.505.4373
or mail them to:
Equitable Life of Canada
Group Disability Claims Department
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
Please note: Equitable Life cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is
intercepted and misused. If you would prefer to submit your information by another means, please contact us at 1.800.265.4556.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
427(2020/06/30) Page 2 of 2
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ONGOING LONG TERM DISABILITY UPDATE 1. Information (Equitable Life of Canada)

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Completed 1 March 2021

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