This document contains both information and form fields. To read information, use the Down Arrow
from a form field.
Your consent
Before we can process your claim for benefits, you must read this agreement and sign in
the signature box below.
Sharing your personal information
We collect, use and disclose your personal information to:
• investigate and assess your claim
• administer your claim and the group benefits plan
• work out a rehabilitation plan to get you back to work
• audit the assessment of the claim.
• manage internal data for analytics purposes
We may also use your social insurance number for income tax reporting and
as an identification number if this is required in the administration of your
benefits.
We may collect and exchange your personal information
with these persons or groups when relevant and necessary
for the purpose above:
• Healthcare and rehabilitation providers
• Insurance and reinsurance companies
• Administrators of the plan, of government benefits and of other benefit
programs
• Your employer, plan sponsor and plan administrator, for the purpose of
discussing return to work planning
• Your employer’s occupational health services
• Your union representative
• Service providers and other organizations working with us, or on behalf of the
other parties mentioned above. We may use service providers outside Canada.
• An auditor authorized by us, your employer, plan sponsor or their agent
Protecting
your privacy
We take your privacy seriously. We
keep all your personal information
in a confidential file in our offices, or
the offices of an organization we’ve
authorized. The only persons with
access to the information are:
• people working at Canada Life and
those we’ve authorized, who need
the information to do their jobs and
manage your claim
• those whom you’ve given access
• those authorized by law both within
Canada and in any other jurisdiction
where your personal information is
held.
For a copy of our Privacy Guidelines
see canadalife.com or you can
write to Canada Life’s Chief
Compliance Officer.
By signing below, you confirm that:
• You have read, understand and agree with the contents
of this form and authorize us to collect and disclose
your personal information.
• Except for audit purposes, your authorization is valid for
the duration of your claim or until you cancel it in writing.
• All statements you have made about your claim are true
and complete
• A photocopy or electronic copy of this authorization is
as valid as the original.
canadalife.com • 1-855-755-6729
M7415-1/20
© 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.
Your group plan number Print your name Telephone number
Your Canada Life ID number Email Address
Enter your email address if you would like
Canada Life to communicate with you by secure
email about your Disability Services claim.
Your signature Date (mm/dd/yyyy)
