City or town Province Postal code
Number and street Province Postal code
Number and street City or town Postal code
Number and street City or town Province Postal code
Day Month Year
Plan Member signature X
Date:
Plan name
Plan number Plan member I.D. number
First name Last name
Number and strNumber and street eet City or town City or town PrProvince ovince Postal code
Date of birth:
Day Month Year
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Page 1 of 2 PLEASE COMPLETE PAGE 2 OF STATEMENT
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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M7464-2/20
© 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.
WELLNESS/LIFESTYLE ACCOUNT
EXPENSES STATEMENT
INSTRUCTIONS:
1. Complete this form in full. Sign and date the form.
2. Please attach original receipts along with the form.
3. Please retain copies for your files as original receipts will not be returned.
4. Send to the appropriate Benefit Payment Office for your plan. See PART 4.
PART 1 - Confirmation, Authorization and Signature
I certify that the information given on this claim form is true, correct and complete to the best of my knowledge. I certify that all goods and services being claimed have
been received by me, my spouse and/or my dependents; and that my spouse and/or dependents are eligible under the terms of my plan.
The submission of fraudulent claims is a criminal offence. Canada Life takes the submission of fraudulent claims seriously. Suspected fraudulent claims may be reported
to your employer or plan sponsor and to the appropriate law enforcement agency.
At Canada Life, we recognize and respect the importance of privacy. Personal information that we collect will be used for the purposes of assessing your claim and
administering the group benefi ts plan. I authorize Canada Life, any healthcare or dentalcare provider, my plan administrator, other insurance or reinsurance companies,
administrators of government benefi ts or other benefi ts programs, other organizations or service providers working with Canada Life located within or outside Canada, to
exchange personal information when necessary for these purposes. I understand that personal information may be subject to disclosure to those authorized under
applicable law within or outside Canada.
I also consent to the use of my personal information for Canada Life and its affi liates’ internal data management and analytics purposes.
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.
PART 2 - Plan Member Information You must complete this section fully. If you are unsure of your plan name, plan number or plan member
I.D. number, please contact your plan administrator.
Plan Member Name
Plan Member Address
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