Form Gl4497E PDF Details

Form Gl4497E is a form that is used to report the sale of a motor vehicle. This form must be filled out by both the seller and the purchaser of the vehicle, and filed with the Department of Motor Vehicles. The Form Gl4497E can be used when selling or purchasing a car, truck, motorcycle, or any other type of motor vehicle. Knowing how to fill out this form correctly is important for ensuring that the sale goes smoothly.

Form NameForm Gl4497E
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesgb_admin_gl4497 e grpcfs form

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Group Benefits

Premium Pre-Authorized Debit (PAD)

When to use this form: For pre-authorized debit payment of premiums for Group insured and/or Administrative Services Only (ASO) billed in advance financial agreements as calculated by Manulife.

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)


City or town




Postal code















Name of person to be contacted


Email address of person to be contacted










Group contract number

All billing divisions



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


Change PAD


Termination of PAD

Business agreement*

Business agreement*


Business agreement**

*Attach a blank cheque marked “VOID” and complete the


**The LaunchPlan™ - PAD is the mandatory

banking details below.



payment method. Termination of PAD will result in




termination of the contract.





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



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


Transit number


Bank number


Account number







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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

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

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 Pre-Authorized Debit.

10.The Payor acknowledges receipt of a copy of this Authorization, and understanding, acceptance and participation in a PAD plan.

4 Signature




this day of



Signed at



















Per (signature)

































5How to submit the form

Choose one of two available options.

Email scanned form to:


Mail: Premium Administration

Group Benefits

Manulife Financial

PO BOX 1627



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GL4497E (07/2013)