Group Benefits and Pension Update/Changes Update/Changes of Information To be completed and signed by the Employer or authorized Benefit Reps ER#(Required)Employer Name(Required)Effective date of change(Required) MM slash DD slash YYYY Employee ID number(Required)Canada Life member ID numberEmployee Name(Required) First Last Reason for Change(Required)Employment updatePersonal Information updateCoverage updateSalary updateLife insurance beneficiary updateDependent information updatePension contribution updateBenefit class updateUpdate working hours/days/weeksBenefit class and salary updateFor multiple selections, click from the selection + Ctrl to continue selecting more optionsNew legal name First Last New address Street Address City State / Province / Region ZIP / Postal Code New home phone numberNew Cell Phone numberNew personal Email Marital Status(Required) Single Married Other Employee's date of birth MM slash DD slash YYYY Employment status(Required) Employment Termination Employee Resignation Retirement Reinstate employment Disability leave Maternity leave Return to work Transfer of employment Unpaid leave of absence Retiring employee would like to:(Required) Keep extended health and dental coverage via the retiree plan (please submit retiree benefits plan enrolment form) Terminate extended health and dental coverage Benefit Class Class 1 – Permanent F/T or P/T employee Class 2 – Short-term 1-year contract Class 3 – Approved leave of absence (except for Maternity Leave) Class 4 – Ordained priests Class 5 – Retiree member Class 8 – Non-salaried employee (religious order) Class 100 – Pension only (hours dropped below 20 hours/week or earning 35% of the YMPE) Pension contribution Suspend contribution while on leave Reinstate pension contribution Current Employer(Required)New Employer(Required)New annual gross salary(Required)No. of hours worked per day(Required)No. of days worked per week(Required)No. of weeks paid per year(Required)Pension contribution while on maternity leave(Required) Suspend pension contribution while on maternity leave Lower pension contribution level while on maternity leave Reinstate pension contribution Reinstate benefits and pension Reinstate group benefits coverage Reinstate pension contribution Select AllUpdate Group Coverage(Required) Waive coverage (Coverage Information must be provided) Add coverage Benefits while on maternity leave(Required) Continue with all benefits Opting out all benefits while on maternity leave Continue with all benefits and opting out disability benefits Coverage update(Required) Add extended health coverage Add dental coverage Add coverage as a Late Applicant Add coverage for Self, Dependent or Both? Please specify.(Required)Effective date of loss coverage through another plan or date of marriage(Required) MM slash DD slash YYYY Updates on extended health coverage(Required) Waive EHB for Myself and Dependents (Coverage information must be provided) Waive EHB for my dependents only, i.e. Single Coverage (Coverage information must be provided) Reinstate / Keep current extended health coverage Updates on dental coverage(Required) Waive Dental for Myself and Dependents (Coverage information must be provided) Waive Dental for my dependents only, i.e. Single Coverage (Coverage information must be provided) Reinstate / Keep current dental coverage Updates on benefits while on LOA(Required) Not eligible for all benefits and continue with extended health and dental (Class 3) Not eligible for all benefits and opting out extended health and dental (Class 3) Insurance Provider(Required)Policy number(Required)List ALL Primary Beneficiary(ies)Enter the beneficiary’s full name: First Name, Last Name, Relationship to the member and the share %List ALL Contingent Beneficiary(ies)Enter the beneficiary’s full name: First Name, Last Name, Relationship to the member and the share %Trustee for minor beneficiary or contingent beneficiaryEnter the trustee’s full name and contact informationUpdate Dependent(Required) Add dependent Remove dependent Update information Dependent information(Required)First Name, Last name, relationship, date of birth, gender Multiple entries = point formWhat is the new pension contribution level as % of annual gross earnings?(Required)Please enter a number from 1 to 9.Voluntary RPP contribution amount:Voluntary TFSA contribution amount:Voluntary RRSP contribution amount:Authorization and Employer SignatureI, the employer/employer’s representative, certify that I obtained authorization from the above named employee, to apply/update the for coverage information under the group benefits plan issued by Canada Life.(Required) I certify on behalf of the employee that the employee has read and understand and agree with the contents of Canada Life’s Privacy clause stated below.Protecting your personal information. At Canada Life, we’re committed to protecting personal information and respecting your privacy. Personal information is information that either on its own or combined with other information allows an individual to be identified. This includes your name and address, as well as more sensitive information such as your health and financial records. When applicable, this includes information about other people such as your spouse, common-law partner, and children. How we use your personal information. Your personal information is used to provide you with products and services and to improve our business operations. This includes verifying your identity, maintaining your profile, and informing you about features of the products you already have with us. It’s also used to provide you with advice, evaluate your eligibility for products, price our products, collect feedback on our customer service, process claims and other financial transactions, protect you and us from risks such as cyber threats and fraud, and comply with legal obligations. If you provided your social insurance number (SIN), we’ll use it for tax reporting. Your SIN is also used to link your products together and to keep your information separate from other customers with similar names. Who we share personal information with. We share your personal information with other people and organizations who help us administer your products and provide you with services. This may include your advisor or people who work with your advisor, our Canadian subsidiaries, and other organizations that provide us services such as paramedical examiners, medical laboratories, MIB, LLC., specialty coverage providers, independent medical examiners, and pharmacy benefits managers. As well, we may share your information with claims assessors, travel assistance providers, technology suppliers, other insurance or reinsurance companies, other financial institutions, and credit reporting agencies. As part of our day-to-day business, your personal information may be communicated to government departments and agencies, and may be communicated outside your province of residence or outside Canada. We take protecting your personal information seriously and we’ll never sell your personal information to anyone. You’re in control of your personal information. We respect your privacy preferences and follow them when using your personal information. At any point in your relationship with us, you can choose how your personal information is used by updating your privacy preferences through your online account or by submitting a request through our privacy centre at canadalife.com/privacy. This includes choosing whether you receive customer experience surveys, the use of your SIN for non-tax reporting purposes, and whether and how you want to receive information and offers from Canada Life using the personal information we collect from you throughout your relationship with us. You can also exercise other privacy rights through our privacy centre such as access to or correction of your personal information. If you choose to remove your consent to the collection, use and disclosure of the personal information required to serve you and meet our legal obligations, we may not be able to continue to provide you with products and services. Want to learn more? Please visit canadalife.com/privacy. I, the employer/employer’s representative, certify that I obtained authorization from the above named employee, to apply/update the for coverage information under the group benefits plan issued by Canada Life.(Required) I certify on behalf of the employee that I provided the employee with the Authorization and Declaration clause stated below.I, the above mentioned employee applying for the RCAV group benefits and/or pension coverage authorized: • My plan sponsor / employer to deduct from my pay and remit to Canada Life the plan member contributions required under the plan, if applicable; • Canada Life to use my social insurance number for tax reporting purposes and as an identification number where it is required in the administration of the plan; • Canada Life, any healthcare provider, my plan administrator (including Benefit Representative at the local level and the Benefits Administration office), other insurance or reinsurance companies, administrators of government benefits or other benefits programs, other organizations, or service providers working with Canada Life or the above to exchange personal information, when relevant and necessary to determine my eligibility for coverage and to administer the plan. If applying coverage for my spouse and/or dependents, I confirm that I am authorized to act on their behalf. I agree that a photocopy or electronic copy of the Authorizations and Declarations section is as valid as the original. I certify that the information given is true, correct and complete to the best of my knowledge.Employer/Employer Representative's Email Address(Required) Employer/Employer Representative's Name(Required) First Last Employer/Employer Representative's Signature(Required)Upload signed intake form or supporting PDF documentMax. file size: 512 MB. Upload signed pension form or other supporting documentsMax. file size: 512 MB.