Disability Income Benefits
Employee Statement

To begin the claim submission process, you must complete the Employee Statement and the consent form. Please have your doctor complete a physician’s statement.
These forms should be submitted within ten days of the onset of your disability or, if applying for Long Term Disability or a Life Waiver of Premium benefit, no later
than eight weeks before the end of the waiting period. Benefits may be denied if these forms are submitted later than the notice period in your group contract.

NOTE: Canada Life takes the submission of fraudulent claims seriously and will verify the accuracy of the information given in support of your claim.
(| certify that the information given on this claim form is true, correct, and complete to the best of my knowledge.

Your Employer's Name:

Your Plan Numbs Your Canada Life ID Number: E

irst Name: Middle Initial: Last Name:

Gender: [_] Male [_] Female [_] Undisclosed [_] Other

(our Social Insurance Number is required as your disability

Date of Birth: Social Insurance Number: \ Benet may be subject fo income tax deductions.
Home Address:

City / Town: Province / Territory: Postal Code:

Is your mailing address the same as above? !Yes i|No _ Ifno, please provide mailing address.

Mailing Address:

City / Town: Province / Territory: Postal Code:

Location where you work: City / Town: Province / Territory:

Home Phone: (| Confidential (Check the Confidential box if you authorize us to leave a message containing personal \
information about your claim at that number. Otherwise, we will only leave a personal |

Cell Phone: —] Confidential \ message with callback information at that number. /

Work Phone: Ext: CJ Confidential (enter ‘your email address if you would like Canada Life to communicate with
. (ou by secure email about your disability claim.
Email Address:

Your last day of work: (mm/dd/yy) Your first day unable to work: (mm/dd/yy)

During your absence, have you performed any other work? Lj No Yes Describe:

Have you returned to work?

Yes When did you return to work? (mm/dd/yy)

Have you returned to (select all that apply): __] Regular duties and hours __} Modified duties |__| Modified hours

No When do you expect to return to work: (mmidd/yy) OR Unknown OR [_] I'm not planning to return

What is the nature of the medical condition that is/was preventing you from working?

Is your condition work related? _| No L_! Yes

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