r consent

Before we can process your claim for benefits, you must read this agreement and sign in
the signature box below.

S Sharing your personal information
Protecting

We collect, use and disclose your personal information to: .
your privacy

e investigate and assess your claim

¢ administer your claim and the group benefits plan era cp cuaeineeieerets vane

* work out a rehabilitation plan to get you back to work keep all your personal information
* audit the assessment of the claim. 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:

© manage internal data for analytics purposes

We may also use your social insurance number for income tax reporting and
as an identification number if this is required in the administration of your
benefits. © people working at Canada Life and
hose we've authorized, who need
e information to do their jobs and
manage your claim

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 * those authorized by law both within
Canada and in any other jurisdiction

where your personal information is

* those whom you've given access

¢ Administrators of the plan, of government benefits and of other benefit
programs

held.
¢ Your employer, plan sponsor and plan administrator, for the purpose of
discussing return to work planning For a copy of our Privacy Guidelines
* Your employer's occupational health services see canadalife.com or you can

write to Canada Life’s Chief

e Your union representative C li Offi
ompHance icer,

* 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 agen

By signing below, you confirm that:

e You have read, understand and agree with the contents —¢ All statements you have made about your claim are true
of this form and authorize us to collect and disclose and complete
your personal information. * Apho

‘ocopy or electronic copy of this authorization is
¢ Except for audit purposes, your authorization is valid for as valid as the original.
the duration of your claim or until you cancel it in writing.

Your group plan number Print your name Telephone number

Your Canada Life ID number Email Address Enter your email address if you would like
Canada Life to communicate with you by secure

E email about your Disability Services claim.

Your signature Date (mr/dd/yyyy)