Group Benefits and Pension Update/Changes

Benefits & Pension Info Changes

To be completed and signed by the Employer or authorized Benefit Reps

ER#(Required)

Employer Name(Required)

Effective date of change(Required)

Employee ID number(Required)

Canada Life member ID number

Employee Name(Required)

First Last

Reason for Change(Required)

For multiple selections, click from the selection + Ctrl to continue selecting more options

New legal name

First Last (use CAPITAL LETTERS)

New address

Street Address City State / Province / Region ZIP / Postal Code

New home phone number

New Cell Phone number

New personal Email

Marital Status(Required)

Single

Married

Other

Employee's date of birth

Employment status(Required)

Retiring employee would like to:(Required)

Keep extended health and dental coverage via the retiree plan (please complete retiree benefits plan enrolment form)

Terminate extended health and dental coverage

Terminate Registered Pension Plan account after all contributions have been reported

Last RPP contribution was made for the month of :(Required)

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)

Job Title / Role(Required)

No. of hours worked per week(Required)

No. of days worked per week(Required)

Number of weeks paid/worked per year (including paid vacation)(Required)

Pension contribution while on maternity leave(Required)

Suspend pension contribution while on maternity / parental leave

Lower pension contribution level while on maternity / parental leave

Reinstate pension contribution

Reinstate benefits and pension

Reinstate group benefits coverage

Reinstate pension contribution

Update Group Coverage(Required)

Waive coverage (Coverage Information must be provided)

Add coverage

Benefits while on maternity / parental leave(Required)

Continue with all benefits

Opting out all benefits while on maternity / parental 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)

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)

Second ChoiceNot eligible for all benefits and opting out extended health and dental (Class 3)

Insurance Provider(Required)

Policy number(Required)

Reasons for termination of benefits :(Required)

Work hours fall below 20 per week

Others

If "Others", please specify

Please confirm if the employer has received and kept in file the original completed and signed Beneficiary Designation form from the employee.(Required)

I confirm

Upload the completed and signed Beneficiary Desingation form :(Required)

Max. file size: 512 MB.

Upload the completed and signed Designation of revocable beneficiary / trustee appointment form :(Required)

Max. file size: 512 MB.

Upload the completed and signed Change of member information form (if applicable):

Max. file size: 512 MB.

Upload the completed and signed Retiree Benefits Enrolment Form and Pre-authorized debit (PAD) form:(Required)

Max. file size: 512 MB.

Update Dependent(Required)

Add dependent

Remove dependent

Update information

Dependent information(Required)

First Name, Last name, relationship, date of birth, gender Multiple entries = point form

What is the new pension contribution level as % of annual gross earnings? (enter 0 if waived RPP)(Required)

Please enter a number from 0 to 9.

Voluntary RPP contribution amount:

Voluntary TFSA contribution amount:

Voluntary RRSP contribution amount:

Additional Information :

Authorization and Employer Signature

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 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.

Employer/Employer Representative's Email Address(Required)

Employer/Employer Representative's Name(Required)

First Last

Employer/Employer Representative's Signature(Required)

Upload signed form or supporting document

Max. file size: 512 MB.

Upload signed form or supporting documents

Max. file size: 512 MB.