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Group Benefits
Application for Enrolment

PLAN MEMBER INFORMATION

Policy Holder's Last Name

First Name

Date of Birth

Province of Residence

Language

Do you have a spouse?

Sex

PLAN MEMBER ADDRESS

Address

City

Postal Code

Province 

APPLICATION

FOR COVERAGE

I am applying for the Livelii Plan (Life, Health & Dental) for

COORDINATION

OF BENEFITS

Insured Last Name

First Name

Do you or your dependants (spouse and/or children have coverage under another benefits plan?

Date of Birth

Name of other insurer

Effective Date of Coverage

Identification/Certificate Number

Coverage includes; 

Extended Health Benefits

Policy Number

Dental Care

DEPENDANT

INFORMATION

Spouse

Last Name

First Name

Date of Birth

Sex

Spousal Status

Date of cohabitation

Last Name

First Name

Date of Birth

Sex

Special Conditions

BANKING

INFORMATION &

CONTACT

TRANSIT Number

INSTITUTION Number

ACCOUNT Number

AUTHORIZATION

& CONSENT

I hereby apply for coverage (“Coverage”) under the Group Benefits plan issued to my plan sponsor by Manulife. I understand that certain aspects of such Coverage may extend to my spouse and eligible dependants (collectively, “Dependants”). I certify that the information in this form is true and complete to the best of my knowledge. I understand that as the applicant, it is my responsibility to ensure that any further verbal or written statement provided by me, and/or my Dependants, in the future is true and complete to the best of our knowledge. I acknowledge and agree that this Coverage or any portion of this Coverage, and future claims thereunder may be denied or terminated as a result of the provision of false, incomplete, or misleading information. I authorize Manulife to collect, use, maintain and disclose personal information relevant to this application (“Information”) for the purposes of Group Benefits plan administration, audit, assessment, investigation, claim management, underwriting and for determining plan eligibility (“Purposes”). I authorize any person or organization with Information, including any medical and health professionals, facilities or providers, professional regulatory bodies, any employer, group plan administrator, insurer, investigative agency, and any administrators of other benefits programs to collect, use, maintain and exchange this information with each other and with Manulife, its reinsurers and/or its service providers, for the Purposes. I am authorized by my Dependants to consent to this Authorization, on their behalf as if they were signing it themselves, and to disclose and receive their Information, for the Purposes.

If applicable, I authorize Manulife to deposit all payments (“Payments”) due to me from the above referenced Group Benefits policy (“Policy”), into the bank account (“Account”) that I have identified on this form. I confirm that this direct bank deposit authorization applies to the financial institution herein named by me and any other financial institution I choose to name in the future; and shall remain valid until revoked in writing by me, or my duly authorized representative.

I understand and agree that upon the deposit of any Payment(s) into the Account, Manulife is fully discharged from any further liability with respect to such Payment(s). I also understand and agree that Manulife may, at any time and without prior notice, discontinue the direct deposit of Payment(s), as requested herein, and require my personal written endorsement relating to future Payment(s). I also hereby acknowledge and agree that any Payment(s) made by Manulife into the Account, to which I am not entitled, either by contract or by law, shall not form part of my property, and shall be immediately refunded to Manulife, either by me or by representatives of my estate.

If applicable, I authorize Manulife to correspond with me through the email address identified on this form regarding my Coverage, for the Purposes. I understand such correspondence may contain Information; and that the Information is being sent in a manner that is not guaranteed as a secured means of communication. I agree that Manulife is not liable for damages which I may incur as a result of interception by a third party of an email transmission sent by Manulife or by me pursuant to this authorization. I agree should the email address identified on this form change that I am responsible for updating the email address maintained by Manulife. I understand that if I do not wish to receive emails from Manulife, I can remove my email address online or by contacting the Customer Service Centre.

 

I understand that any Information provided to or collected by Manulife in accordance with this authorization, will be kept in a Group Benefits life, health or disability file. Access to my Information will be limited to:

• Manulife employees, representatives, reinsurers, and service providers in the performance of their jobs;

• persons to whom I have granted access; and

• persons authorized by law.

I have the right to request access to the personal information in my file, and, where appropriate, to have any inaccurate information corrected.

I acknowledge that more specific details regarding how and why Manulife collects, uses, maintains, and discloses my personal information can be found in Manulife’s Privacy Policy and Privacy Information Package, available at www.manulife.ca/planmember, or from my Plan Sponsor.

Date signed:

 

ADMIN view only

PLAN SPONSOR STATEMENT

Plan Sponsor Name

Livelii

Plan Contract Number

118605

Account/Location Number

001

Billing Division

NA

Plan Member Certificate Number

NA

Enrolment Date

Class/Plan

Occupation

Frequency

A

3 month waiting period has been completed

Yes

Estimated Annual Earnings

I certify that the plan member listed below is actively working as a sole proprietor or incorporation of one.

Plan Administrator Signature

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Is evidence of insurability required?

No

Date

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Group Benefits
Beneficiary Designation

ADMIN view only

PLAN MEMBER INFORMATION

Plan Sponsor Name

Livelii

Plan Contract Number

118605

Plan Member Certificate Number

{xxxxxx}

Policy Holder's Last Name

Province of Residence

First Name

Date of Birth

PRIMARY

BENEFICIARY

I appoint the following beneficiary(ies) as the person, people or entity who will receive any death benefit from the coverage I have under my benefits plan that becomes payable upon my death at the designated amounts and under the following conditions.

Full  Name

Date of Birth

Relationship 

Percentage %

Irrevocable

CONTINGENT

BENEFICIARY

Full  Name

I appoint the following contingent beneficiary(ies) in the event that all of the primary beneficiaries pass

before me to receive the death benefits . This benefit will be split evenly between the listed contingent

beneficiaries.

Date of Birth

Relationship 

Date of Birth

TRUSTEE

APPOINTMENT

I appoint {Q34a Q34b} as a Trustee to receive any amount due to any beneficiary under the age of majority.

DECLARATION & AUTHORIZATION

Due to the legal significance of a beneficiary appointment, your signature and date on this document will serve as valid and binding.

 

I hereby revoke any previous beneficiary designations in relation to my foregoing coverage(s) and designate the

person(s) named above.

I understand that any Information provided to or collected by Manulife in accordance with this authorization, will be kept in a Group Benefits life, health or disability file. Access to my Information will be limited to:

• Manulife employees, representatives, reinsurers, and service providers in the performance of their jobs;

• persons to whom I have granted access; and

• persons authorized by law.

I have the right to request access to the personal information in my file, and, where appropriate, to have any inaccurate information corrected.

I acknowledge that more specific details regarding how and why Manulife collects, uses, maintains, and discloses my personal information can be found in Manulife’s Privacy Policy and Privacy Information Package, available at www.manulife.ca/planmember, or from my Plan Sponsor.

Date signed:

 
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