Please sign this authorization and send to Manulife using one of the following methods.
Via fax:
(519) 579-3680 or 1-866-677-4215
Via e-mail:
Via regular mail to:
Manulife Group Benefits
Attention: Disability Claims, POThat is Post Office BOX 800, STN C, Kitchener ONThat is Ontario N2G 4Y5
I confirm that the information in this form, and any further verbal or written statement provided by me in the future, is true and complete to the best of my knowledge. I confirm that my claim(s) and my coverage may be denied or terminated as a result of my providing false, incomplete or misleading information. I confirm that I am required to refund any monies that I may owe to Manulife in accordance with the provisions of the group benefits plan with Manulife, and I authorize Manulife to deduct such monies from my group benefits. Manulife will investigate my claim(s) and will require personal information about me, which may include information regarding my activities, income, employment, education, training, health, and medical history and treatment, including clinical notes. I authorize Manulife and/or its service providers, any person or organization who has personal information about me, including any employer, group plan administrator, health care professional, health care institution, pharmacy and any other medically-related facility, rehabilitation provider, insurer and administrator of government benefits or other benefits programs to exchange my personal information for the purposes of group benefits plan administration and audits as well as the assessment, investigation and management of my claims, including independent medical assessments. I authorize Manulife, its reinsurers and its service providers to collect, use, maintain and disclose to the persons or organizations listed above and/or each other any information needed for the purposes of group benefits plan administration, audit, assessment, investigation and management, including independent medical assessments. I authorize Manulife to release information to my employer or a third party advisor of my employer for plan administration and analysis purposes only and I acknowledge that my medical information will not be provided to my employer unless my consent is explicitly obtained. I authorize Manulife to use my SIN for the purposes of tax reporting and identification and administration, if my SIN is used as my plan member certifi cate number. I confirm that a photocopy or electronic version of this authorization shall be as valid as the original. I understand 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, available at www.manulife.ca/planmemberopens in new window or from my plan sponsor. I acknowledge that any personal information provided to or collected by Manulife in accordance with this authorization will be kept in a group life, health, or disability benefits file. Access to, or disclosure of, my personal 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 or authorized disclosure; and
- persons authorized by law.
I authorize Manulife Financial to release to and exchange with Costco Wholesale Canada Ltd.'s Regional Disability Manager information gathered regarding my diagnosis, degree of impairment, treatment plan, restrictions, functional limitations, and any obstacles to return to work that are identified through the adjudication and rehabilitation process in order to assist with return to work planning.
Please note : The information in this statement will be kept in a group life, health, and/or disability case file with Manulife and might be accessible by the employee or third parties to whom access has been granted or those authorized by law.