Street address:
City: Province: Postal code:
Name of insured:
last name first name middle initial
Date of birth: Month Day Year
•
Plan number:
Division number: Plan member ID:
Plan sponsor:
Plan member name (print):
last name first name middle initial
•
Plan member signature: Date:
Please print clearly in INK.
Ple
ase print clearly in INK.
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
OPTIONAL CRITICAL ILLNESS
APPLICATION FOR NON-SMOKER RATE
For CL Head Office Use Only
CL Certificate Number
Please print clearly and complete this form, in INK and send to: The Canada Life Assurance Company
Attn: Member Administration
PO Box 6000
Winnipeg MB R3C 3A5
1. General enrolment
information
This section is to be completed by
the plan member.
2. Plan member
information
This section is to be completed by
the plan member.
Plan member mailing address:
3. Smoking declaration
This section is to be completed
by the insured (plan member. or
spouse)
i) Within the past 12 months have you smoked or used cigarettes, e-cigarettes,
cigarillos, pipe, cigars, nicotine patch and/or gum, chewing tobacco, hookah,
or tobacco or nicotine products in any other form?
Yes No
ii) In the past 2 years have you been treated for or had any indication of
heart disease, stroke, cancer, or any respiratory disease or disorder?
Yes No
4. 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.
5. Authorizations and
declarations
This section must be signed and
dated in INK by the plan member.
I have read and understand and agree with the contents of the section on this form entitled “Privacy”.
I authorize:
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.
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.
www.canadalife.com 1-800-957-9777
M7064-1/20 © 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.
