The Gl4497E form is an essential document for businesses that opt for a seamless, automated method for paying their group benefits premiums to The Manufacturers Life Insurance Company, better known as Manulife. Designed to facilitate pre-authorized debit (PAD) payments for premiums associated with Group insured and/or Administrative Services Only (ASO) agreements that are billed in advance, this form streamlines the financial transactions between businesses and the insurer. It outlines specific criteria regarding its use, such as when it is appropriate—explicitly for pre-authorized debit payment of premiums under certain financial conditions—and when it should not be used, particularly for benefits under any ASO agreement billed in arrears. Furthermore, the form requires detailed information from the plan sponsor or the payor, including banking details and a clear acknowledgment of the terms associated with initiating, changing, or terminating PAD arrangements. Notably, the document emphasizes the importance of providing accurate banking information, attaching a voided cheque, and understanding the procedures for changing banking details. It also clarifies the authorization given to Manulife for issuing PADs on the payor's behalf and the rights and obligations of both parties involved in this agreement. In addition, it provides guidance on how to submit the completed form, offering two submission options for convenience. This overview of the Gl4497E form underscores its role in ensuring a straightforward and efficient payment process for group benefits premiums, benefiting both the payor and Manulife.
| Question | Answer |
|---|---|
| Form Name | Form Gl4497E |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | gb_admin_gl4497 e grpcfs form |
Group Benefits
Premium
When to use this form: For
When not to use this form: For any benefits with an Administrative Services Only (ASO) billed in arrears financial agreement.
1 Plan sponsor information Plan sponsor (the “Payor”)
Plan sponsor/Payor's address (number, street, suite) |
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City or town |
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Province |
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Postal code |
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Name of person to be contacted |
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Email address of person to be contacted |
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Group contract number |
All billing divisions |
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List specific billing division(s) ____________________________________________ |
One PAD form is required when PAD is to be drawn from one bank account for all divisions.
A separate PAD form is required for each division, when PAD is to be drawn from different bank accounts.
2Payor's banking information
New PAD |
Change PAD |
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Termination of PAD |
Business agreement* |
Business agreement* |
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Business agreement** |
*Attach a blank cheque marked “VOID” and complete the |
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**The LaunchPlan™ - PAD is the mandatory |
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banking details below. |
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payment method. Termination of PAD will result in |
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termination of the contract. |
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PAD pull date
Under 100 lives: The LaunchPlan, AlphaPlus® and Signature
• PAD pull date will default to the 10th of each month. No other date options are available for these products.
Greater than 100 lives: Signature or Corporate
Select PAD pull date |
10th |
20th |
•If you select 20th as your PAD pull date, your bill generation date must be 25th or later.
•PAD pull date can be changed upon the renewal of your policy.
Name of financial institution
Address
Transit number |
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Bank number |
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Account number |
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TheManufacturersLifeInsuranceCompany |
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GL4497E (07/2013) |
3 Acknowledgment
The payor acknowledges that this Authorization is provided for the benefit of the payee, The Manufacturers Life Insurance Company ("Manulife"), and the Processing Institution and is provided in consideration of the Processing Institution agreeing to process debits against the Payor's account set out above (the "Account") in accordance with the rules of the Canadian Payments Association.
1.The Payor acknowledges that provision and delivery of this Authorization to Manulife constitutes delivery by the Payor to the Processing Institution.
2.The Payor certifies that the above banking information is accurate and complete. A specimen cheque marked "void" has been attached to this Authorization. The Payor agrees to inform Manulife in writing of any change in the Account information 10 days prior to the next due date of the PAD. New PAD Agreements received at Manulife 10 days prior to your next bill run will become effective on the next Group Benefits Billing Statement.
3.The Payor warrants and guarantees that all persons whose signatures are required to sign on this Account have signed this Authorization and that all persons signing this Authorization are authorized signing officers empowered to enter into this agreement.
4.The Payor hereby authorizes Manulife to issue PADs drawn on this Account with the Processing Institution on a monthly basis on or after the 10th of each month, or the 20th if selected for the following purposes:
• Payment of premiums for Group Insurance as calculated by Manulife.
The Payor authorizes the Processing Institution to deal with these withdrawals as if they were signed by the Payor.
5.The Payor and Manulife agree that the amount of the PAD authorized by this Authorization may vary from month to month, according to the amount due on the most recent Billing Statement, as calculated by Manulife in its discretion according to policy administration information supplied by the Payor. Any payments or adjustments processed after the date prepared on the most recent Billing Statement will be reflected on the next Billing Statement.
6.The Payor acknowledges that the Processing Institution is not required to verify that a PAD has been issued in accordance with this Authorization including, but not limited to, the amount; nor is the Processing Institution required to verify that any purpose of payment for which the PAD was issued has been fulfilled by Manulife.
7.This Authorization may be revoked by the Payor upon 10 days’ written notice. If PAD is a mandatory payment method for your Group Contract termination of the PAD will result in termination of the Contract.
•The Payor may obtain a sample cancellation form, or further information on their right to cancel a PAD Agreement, at their financial institution or by visiting www.cdnpay.ca.
8.The Payor has certain recourse rights if any debit does not comply with this agreement. For example, the Payor has the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on recourse rights, the Payor may contact their financial institution or visit www.cdnpay.ca.
9.The Payor consents to the disclosure of any personal information contained in this Authorization to Manulife's bank, but only as far as any such disclosure is directly related to and necessary for the proper application and processing of the
10.The Payor acknowledges receipt of a copy of this Authorization, and understanding, acceptance and participation in a PAD plan.
4 Signature |
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this day of |
(dd/mmm/yyyy) |
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Signed at |
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Payor |
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Per (signature) |
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Name |
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Title |
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5How to submit the form
Choose one of two available options.
Email scanned form to: GRP.CFS.PAD@manulife.com
OR
Mail: Premium Administration
Group Benefits
Manulife Financial
PO BOX 1627
WATERLOO ON N2J 4P4
TheManufacturersLifeInsuranceCompany |
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GL4497E (07/2013) |