Term Life Insurance Authorization
Notice about MIB Inc.
Your personal information will be treated as confidential. Canada life or its reinsurers may, however, make a brief report to the MIB Inc., a non-profit membership organization of life insurance companies which operates an information exchange on behalf of its members. If you apply to another bureau member company for life or health insurance or submit a claim for benefits to such a company, the bureau will upon request supply the company with the information it may have.
Canada Life or its reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance, or to whom you submit a claim for benefits. The company will not, however, reveal to another company or to the bureau the action taken on the basis of your current request for insurance.
If you wish to see the information in your bureau file or have it corrected, please contact the bureau’s information office at:
Suite 501, 330 University Avenue, Toronto, ON M5G 1R7, Tel 416.597.0590
Protecting your personal information
At the Canada Life Assurance Company we recognize and respect the importance of privacy.
Your personal information:
When you apply for coverage, we establish a confidential file that contains your personal information like your name, contact information, and products and coverage you have with us. Depending on the products or services you apply for and are provided with, this may also include financial or health information. Your information is kept in the offices of Canada Life or the offices of an organization authorized by Canada Life. You may exercise certain rights of access and rectification with respect to the personal information in your file by sending a request in writing to Canada Life.
Who has access to your information:
We limit access to personal information in your file to Canada Life staff or persons authorized by Canada Life who require it to perform their duties and two persons to whom you have granted access. In order to assist in fulfilling the purposes identified below, we may use service providers located within or outside Canada. Your personal information may also be subject to disclosure to public authorities or other authorized under applicable law within or outside Canada.
What the information is used for:
Personal information that we collect will be used for the purposes of determining your eligibility for products, services or coverage for which you apply, providing, administering or servicing products or coverage you have with us, and for Canada Life‘s and its affiliates internal data management and analytics purposes. This may include investigating and assessing claims, paying benefits, and creating and maintaining records concerning our relationship. The consent given in this form will be valid until we receive written notice that you have withdrawn it, subject to legal and contractual restrictions. For example, if you withdraw your consent, we may not be able to continue to adjudicate or administer a claim for benefits.
If you want to know more:
For a copy of our privacy guidelines, or if you have questions about our personal information policies and practises [including with respect to service providers], write to Canada Life’s Chief Compliance Officer or refer to www.canadalife.com.
Authorization and declaration:
Canada Life, any healthcare provider, my plan administrator, other insurance companies or reinsurance companies, the MIB Inc., administrators of government benefits or other benefits programs, other organizations, or service providers working with Canada Life to exchange personal information, when necessary to determine my insurability and to administer the group benefits plan;
Canada Life to release my medical records to the regular healthcare provider or clinic named in this application including any test results that may be obtained during the application process;
Canada Life to communicate with me about this application, with electronic messages, using either the mobile number or the email address I have provided;
My plan sponsor to deduct from my pay and remit to Canada Life the plan member contributions required under the plan if applicable.
I certify or confirm that:
I am actively at work on the date this application is signed;
I have read and agree with the important notice describing the procedures of the MIB Inc.;
I have retained a copy of this application;
If applying for coverage for dependence, I am authorized to act on their behalf;
A photocopy or an electronic copy of this authorization is as valid as the original.
The statements and answers on this form will be used to determine your insurability and provide benefits under the plan. Any changes in the accuracy of any of the statements and answers on the form between the date this form is signed and the effective date of any coverage approved by Canada Life must be reported to Canada Life. I understand if I failed to do so, any coverage granted may be void.
I declare that to the best of my knowledge, all the above answers to the questions are completed and true. I understand that if any answer is incomplete or false, any coverage granted may be void. I understand that I may be refused for coverage for all or part of any benefit if, in the opinion of Canada Life, I am not insurable for all or part of that benefit.
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