Mark Holand
June 30, 2026
Page 2

REPORTABLE INCOME & INCOME DECLARATION FORM

For the duration of your claim for benefits, it is your responsibility to notify Canada Life of:

e Any work performed, whether or not you have received a wage or remuneration, or
e Any employment income paid to you or any other person or party as a result of work

performed by you.

REPORTABLE INCOME

Reportable income means all of the following kinds of benefits, earnings and income. It is income, which

may affect, or be affected by, the amount of benefit payable under this group policy.

Have you applied for any of the following income?

No Vv

Yes Please complete the appropriate section below. Attach a copy of the documentation
outlining the decision for each application.

Type of Reportable Date Status of If accepted, Amount of

Income applied for application indicate effective payment
other Accepted, Pending, | date of reportable | and
income or Declined income frequency

Employment income
(from self-employment,
part-time work, board of
director fees, etc.)

Canada Pension Plan —
Retirement Income

Canada/Quebec Pension
Plan — Disability Income
(not including Dependent
benefits)

Canada/Quebec Pension
Plan — Dependent’s
Benefits

Disability benefits under
any group, association
or franchise plan

Disability benefits under
any other government
plan, excluding
Employment Insurance
benefits

Workers' Compensation
(Wage Loss)

Workers' Compensation
(benefits other than
Wage Loss)