Last name of plan member:

First name of plan member:

Middle initial:

Date of birth: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Sex: Male Female

Province of residence: AB BC MB NB NF NS ON PE QC SK YT NT NU AL AK AZ AR CA CO CT DE DL FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX VT VA WA WV WI WY

Language of preference: English French

Address (number, street, apt. number):

City:

Province: AB BC MB NB NF NS ON PE QC SK YT NT NU AL AK AZ AR CA CO CT DE DL FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX VT VA WA WV WI WY

Postal code:

Health:

Dental:

Dependant life: Yes No

If you have eligible dependants, refusal of this benefit is not allowed on an AlphaPlus plan.

Click here if you do not have a spouse. The spousal coverage information does not need to be completed.

Complete this section only if you are required to enrol your spouse and/or dependants.

• If more than 4 children, please send a note.
• If requesting family coverage, please ensure your spouse and children are listed below, regardless of whether they have health or dental care coverage under another plan.

Relationship codes: H = Husband, W = Wife, S = Common-law spouse, C = Child

Complete the section below to sign-up for following services:

• Direct deposit of your claim payments
• Electronic claim statements
• Provider eClaims

Name of financial institution:

Transit number:

Institution number:

Bank account number:

Work email:

Personal email:

The beneficiary will be ESTATE. If you would like to designate a named beneficiary other than "ESTATE" you must complete, print and sign form GL1435E(Snet), e-Beneficiary Designation. You can submit that form to your Plan Administrator or mail directly to Manulife Financial.

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 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.

Plan member's authorization and certification is given upon submission of this form.