Form Gl3817E Lh – Fill Out and Use This PDF

Group Benefits

Plan member/Dependant Enrolment/Change

Please print clearly, complete all pages and ensure form is signed. Mandatory fields ( * ) must be completed.

Date (dd/mmm/yyyy)

1Plan member information

To be completed by plan sponsor

All changes must be submitted within 31 days from the effective date of the change, or Manulife Financial will require evidence of insurability.

Type of change - Check ( )

Health

Dental

Prescription Drugs

Life

Dependant Life

AD&D

Weekly Indemnity

Travel

Hospital

Vision

Long term disability

Critical illness

Managed dental care

Dental centre number

Co-ordination of benefits

If you do not have a spouse, this section does not apply.

Spouse's date of birth (dd/mmm/yyyy)

3Change of beneficiary

If more space is required, please complete a second form and attach.

Percentages must total 100% to be valid.

In accordance with the terms and conditions of the Group Life Contract between the plan sponsor indicated below and Manulife Financial, I revoke all previous appointments of beneficiary and hereby appoint the following as beneficiary entitled to receive the proceeds arising by reason of my death.

%

3Change of beneficiary (continued)

Under the laws of the Province of Quebec, any designation of a spouse as a beneficiary is irrevocable unless stipulated to be revocable.

I hereby declare and stipulate that the beneficiary designations made on this form are revocable.

Note: If you designate a minor child as the beneficiary of your insurance proceeds, these proceeds will be paid into court, unless a trustee is appointed to receive such benefits on behalf of such child.

Trustee appointment (you may wish to consult a lawyer before appointing a Trustee).

Plan contract number

Plan member certificate number

Last name

5Waiver of Benefits

(To be completed and signed by plan member - If not applying for coverage)

I have been given the opportunity to apply for coverage but do not wish to participate. I understand that if I wish to request coverage at a later date, I will be required to furnish, at my own expense, for myself (and if applicable, for my eligible dependant(s)) evidence of insurability satisfactory to Manulife Financial. For Dental coverage, benefits will be limited during the first 12 months of coverage.

6Authorization

To be signed by plan member

I hereby apply for coverage ("Coverage") under the Group Benefits plan issued to my plan sponsor by

Manulife Financial ("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. I authorize my plan sponsor to make deductions from my pay for my Group Benefits plan, if applicable. I authorize the use of my Social Insurance Number ("SIN") for the purposes of identification and administration, if my SIN is used as my plan member certificate number. I agree a photocopy or electronic version of this authorization is valid. I designate the person(s) named above under Beneficiary Designation, as my beneficiary.

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/groupbenefits, or from my Plan Sponsor.