Have you applied for, or are you receiving any income either as a result of your disability or otherwise (please check no or yes)?
© Canada Pension Plan/Quebec Pension Plan or Worker's Compensation Board Benefits (or similar benefits). [/No [_] Yes
Any other income? Examples: automobile accident benefits, employer sponsored STD or sick leave benefits, Employment Insurance benefits, retirement

or pension plan income. No Yes.

If you answered yes, attach a copy of the initial benefits statement for each type of other income.

© Self employment or other employment income. [_] No [_] Yes.
If you answered yes, attach a copy of your pay/salary details.

All of the income described above is referred to as “reportable income”.

if you have any of the following coverage with Canada Life or London Life, please select all that apply:
_] Individual Disability Insurance Plan#
_| Individual Life Insurance Plani#
Creditor/Loan Insurance Plani#
Critical Illness Insurance Plan#
_| Guaranteed Standard Issue

Note: If you have Guaranteed Standard Issue coverage with Canada Life this form will be used as notice of claim for that coverage as well.

Provide your banking information or attach a void cheque where you want your disability benefits to
be deposited to. If space is left blank, previously provided banking information for other benefits under
this group plan (i.e. Healthcare or Dentalcare) will be used for any disability income benefits payable.

Name of bank/credit union:

Transit number: I Institution number: Account number:

wooo woae 4400 i b234 Ghee Pe

TRANSIT# INSTITUTION# ACCOUNT#

(| declare the information I’ve entered is accurate. | understand and agree to the terms in the Income Declaration and Reimbursement Agreement section. |
also acknowledge that I need to print, sign, and submit my Consent Form to Canada Life.

Signature: Today's date:

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