Is your condition the result of an accident? |_| No |_| Yes _ If yes, answer the following questio!

When did the accident occur? (mm/dd/yy)
Provide details of the accident

Was the accident a motor vehicle accident? [_] No[-] Yes In what province did your accident occur?

Were you admitted to a hospital? No Yes Hospital Name:

Date admitted: == (mm/dd/yy) §= Date discharged: = (mmddyy) §9=OR Still hospitalized
Have you had surgery since being off work, or is surgery planned? No Yes
Date of surgery: Type of surgery:

Is recovery from your surgery the only medical condition keeping you from working? [_]No (J Yes [] Unknown

Please provide the following information of your health care provider related to this claim:

Primary Physician: Specialty:
Address: Phone Number:
Do you have other health care providers related to this claim? []No [Yes if yes, provide details.

Provider Name: Specialty:
Address: Phone Number:
Provider Name: Specialty:
Address: Phone Number:

| understand that:

| am required to apply for disability benefits that | or another member of my family might become entitled to receive because of my disability, and that

| may be asked by Canada Life to reapply or appeal decisions refusing my application(s) where considered appropriate.

* during the time it takes for my application for these other disability benefits to be accepted, or my entitlement to any other reportable income to be
reviewed, Canada Life will continue paying me amounts equivalent to the disability benefit payments | am eligible to receive under the Group Plan,
provided | continue to be eligible for these disability benefit payments under the Group Plan (the “Advance’). The terms “other disability benefits”
and “other reportable income” refer to any of the types of disability benefits and other income mentioned under the Offset, All Source Maximum,
Coordination of Benefits and Subrogation and Right of Recovery provisions under the Group Plan, as well as any other amounts, including damages
for loss of income, that | may receive or become entitled to receive as a result of my disability.

* if | am entitled to receive disability benefits or any other reportable income, this may result in an overpayment (“Overpayment”) that | will be required
to pay back to Canada Life. | specifically give up my rights under any law that qualifies the Advance, the Overpayment, the other disability benefits, or
any other reportable income, as property exempt from seizure.

* Canada Life may reduce my disability benefit payments by the amount of other disability benefits or other reportable income that | receive or become
entitled to.

lagree to:
* notify Canada Life within 15 days of receipt of other disability benefit payments or any other reportable income.

* repay Canada Life within the time frame Canada Life advises me of after | am notified of the Overpayment amount or within a longer period if
Canada agrees in writing. | understand that if the Overpayment is not repaid when due, Canada Life may take all necessary steps to recover the
Overpayment, including withholding the payment of, or recovering the Overpayment from, any benefits payable under the Group Plan.

canadalife.com + 1-855-755 The Canada Life Assurance Company, all rights reserved, Canada Life and design are trademarks of The Canada Life Assurance Comp>™
M7413-1/20 Any modification of this document without the express written consent of Canada Life is strictly prohibited. 000236