5/14/2026, 12:53 PM EDT TO: +16045227206 FROM: 18335201506 OPIFINY PAGE 5/5

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Your consent

Before we can process
box below,

G) Sharing your Personal information

We collect, use and d

Isclose your rso: .
. dil lit vention Personal information to:
* Aaminister your claim andthe group benef plan

® WOrk out a rehablitation 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 i 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 goverment benefits and of other benefit programs

© Your employer, plan sponsor and plan administrator, for the purpose of discussing retum to
work planning

« Your employer, plan sponsor, plan administrator, and your employer's occupational
health services, for the purposes of an aut or an internal appeal. This inchudes medical

© 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

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.

complete

Your clalm for benefts, you must read this agreement and signin the signature

a a eae,
Protecting
your privacy

We take your privacy serlously. 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 bath 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.

heii)

© All statements you have made about your claim are true and

© A photocopy or electronic copy of this authorization is as valid as

© Except for audit purposes, your authorization is velid for the duration the original,
of your claim or until you cancel it in writing.

‘Your group plan number Print your name
‘50788 Mark Holand
Your Canada Life 10 number Email Address

F21987
Your signature
x fev)

marktholand@gmail.com

canada ifel

Telephone number
236-994-3376 __ Boll aes
Enter your email ackiress if you would fe
‘(Canscia Life to communicate with you by |