The Canada Life Assurance Company

™
)-f) Vancouver Disability Management Services
canada 2 PO Box 1055
aS

Winnipeg, MB R3C 2X4

Tel 604-646-1200 / 1-888-292-4111
Fax 1-844-816-1038
vancouver.dmso@canadalife.com
canadalife.com

REIMBURSEMENT AGREEMENT
PID # 130684485

Name Mark Holand
Group Plan Number 51292/51295
WorkSafeBC Claim Number 42647461

|, Mark Holand__, have made a disability claim to Canada Life under Group Plan Number 51296. If |
am eligible for the Board benefits, then | am not entitled to disability payments from Canada Life (or my
payments from Canada Life are reduced by any benefits received from the Board).

In consideration of the payments made to me by Canada Life, |:

. Agree to immediately submit a complete and proper claim to the Board and to actively pursue the
claim to a final decision.

. Authorize and direct the Board to disclose to Canada Life Assurance Company any information
pertaining to any Board awards | am, or may be entitled to.

. Authorize and direct the Board to pay directly to Canada Life the full amount of the benefits which
Canada Life certifies it has paid to me under this group plan with respect to my disability.

. Agree to promptly reimburse Canada Life for any overpayment of benefits that may occur if the

Board does not honor this assignment or if the amount paid to me by Canada Life is more than
any amount it obtains from the Board.

July 2, 2026

Signature Date