Group Benefits Enrolment Application Form (Page 3 of 3) in pdf

9 Plan member signature

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

, or from my Plan Sponsor.

Please sign and date here.

Plan member's signature

Date signed (dd/mmm/yyyy)

Please send the completed form to:

10 Mailing instructions

Plan Member Administration

Manulife Financial

PO BOX 2026

HALIFAX NS B3J 2Z1

For Manulife Financial use only

Effective date of

Multiple

CLASS MODE

SAL

LIFE

A D & D

LTD

EHC

DEN

DEP.

OCC

DIV

COB

DRUG

LATE EE

LATE

MNL

CII EVA

Insurance

Group No.

LIFE

PLAN

DEP

dd/mmm/yyyy

Cov Indicator

Expiry date

Tax Exempt

Multi Accts

EXCESS

HCSA

SENT NOTE

Initials

The Manufacturers Life Insurance Company

Page 3 of 3

GL2971E (09/2007) GP/MC

Group Benefits Enrolment Application Form Page 3

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