Claim form Completion of all relevant fields will ensure prompt assessment of the claim Life Claims Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Tel: 0117 916 4460 Fax: 01707 671180 Email: Grouplifeclaims@canadalife.co.uk
Important information please read prior to completion of Claim form When should a trustee/authorised signatory submit a claim form? As soon as possible after a member s death. We will not pay any benefit, or any additional amounts of benefit, if a completed claim form, in respect of the benefit being claimed, has not been received by us within two years of the date of a member s death. How to submit a claim? If you wish to make a claim, we will initially need: a fully completed original claim form signed by the scheme trustees, or other agreed signatories Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Section 7 Section 8 Lump sum 3 3 3 if applicable 5 5 3 3 Pension 3 5 3 if applicable 3 3 3 3 evidence of a member s earnings where individual scheme data has not been provided at the commencement of risk or subsequently at the commencement of the current rate guarantee period (evidence can be copies of a member s last three full pay slips, a member s P60 for the last tax year or a P14). a member s original death certificate. where a spouse s/civil partner/dependant s pension is to be claimed, an original birth certificate for the spouse/civil partner and any other dependant and if applicable an original marriage certificate/civil partnership certificate for spouse/ civil partner. If the pension is payable to a person who is not the member s spouse/civil partner or child, we will also require: a copy of the current Scheme rules, a copy of the trustees investigations where they have established financial dependency in accordance with the Scheme rules. Original certificates will be returned to sender by recorded delivery as efficiently as possible. If the policy has been set up under the Canada Life Group Life Master Trust then an additional Master Trust Family Information Form will be required. Contact the life claims team for details. Why does Canada Life require original certificates? Due to HMSO directives relating to copyright, we are unable to accept photocopies. It should also be noted that having sight of the original documentation also reduces the risk of fraud. How long will it take to process my claim? Once we have received all our initial requirements, we will advise you within five working days: of any further information we require to assess the validity of the claim, or if we are unable to admit the claim and the reason(s) why. How will benefits be paid? If your claim is accepted, our settlement of any lump sum benefit will normally be remitted by Electronic Fund Transfer, in the name of the trustees of the scheme, direct into the trustee bank account. Payments will not normally be made to parties other than the trustees of the scheme. If the policy has been set up under the Canada Life Group Life Master Trust, payment will be made via Electronic Transfer direct to the beneficiary(ies). Does Canada Life offer any support services? A confidential 24-hour bereavement counselling and probate helpline is available for family members. 2
Section 1 Please ensure this section is fully completed for all claims. If the name on the deed is different to that on our records, please notify us. Principal employer s name Employer s name (if different from above) Group policy number Section 2 Payment details Payment to be made (please select one only) Please record trustee bank account details below in all cases where a lump sum is being claimed. Payment by other means will delay settlement. Canada Life will not make payment to a company trading account. Payment should only be made to a dedicated trustee bank account. If the trustees require payment to other than a trustee account (direct to beneficiaries) please arrange for completion of an authorisation and discharge form. To Trustee s Bank Account Please complete the account details section below. Direct to beneficiary(s). Authorisation and discharge attached/to follow. Via Canada Life Group Life Master Trust An additional Master Trust Family Information Form will be required. Please contact the life claims team as below. Trustee s bank account details Trustees account name Only complete with dedicated trustee bank account details. If in doubt please contact us. (t required for Master Trust) Trustees of Name of bank Branch Bank sort code Account number Authorisation and discharge forms must be completed on the policyholder s headed paper. Up to 3 named beneficiaries (individuals/charities) can be included on an authorisation and discharge form. Payment will not be made direct to the estate of the deceased or to a trust account which is not the trust used for creation of the group life scheme. Wording and full details can be obtained by contacting the life claims team on 0117 916 4460. Section 3 Deceased member s details Member s full name Fully complete for all claims. Date of birth Employment start date If the member did not join the scheme when first eligible, please provide full details / explanation On what date did the member last attend work? Category for cover (eg works, staff, director etc) Scheme salary applicable at date of member s last attendance at work Benefit calculation (eg 3 x scheme salary) Amount of lump sum benefits being claimed Basis upon which the benefit is calculated. Date of death Scheme inclusion date (if different from employment start date) Scheme salary applicable at date of member s death Place of work postcode 3
Section 4 Death occurring overseas Particulars of deceased Date of departure from the UK Intended date of return to UK Last UK address Please complete if death occurred overseas. Please ensure that the original death certificate is provided along with an official translation in cases where no UK death certificate has been issued. Country visited Purpose of visit (e.g. business, holiday) Passport number Details of death Address abroad at time of death Exact place of death Exact time of death Exact cause of death Was it an accident? If please complete Accident section. Was it an illness? If please complete Illness section. Accident How did the accident occur? Who witnessed the accident? Please give names and addresses Was a police investigation carried out? Please provide a copy of the report if available. To which hospital was the deceased taken? Name and address of doctor certifying death Was there a post-mortem? Please provide a copy of the report if available. Was there an inquest? Please provide a copy of the report if available. Illness When was the deceased first taken ill? Nature of illness Name and address of medical attendant during last illness Name of doctor certifying death Burial/cremation Was the deceased: Buried? Cremated? Please tick the appropriate box. What documentation was obtained to allow the burial or cremation to take place? Where did the burial/cremation take place? Please provide the name and address of one person, not related to the deceased, who was present at the burial/cremation 4
Section 5 Spouse s/ civil partner s/ dependant s details Spouse s/civil partner s/ dependant s full name Date of birth This section only needs to be completed if a spouse/civil partner, dependant s or children s pension needs to be claimed. National Insurance number Basis of calculation of pension Annual amount of pension (payable on the member s death in accordance with the policy) If the spouse s/civil partner s/dependant s pension claimed includes any differing levels of escalation please provide the amounts and the levels of escalation below. Level of escalation e.g. Nil, LPI, 5% Amount of pension (NB: The pension amounts must equal the annual amount of pension shown above.) Post A-Day Pre A-Day HMRC maximum annual pension for the spouse/civil partner/dependant (if applicable) Details of any qualifying children where children s benefits are payable Full name Date of birth Child s annual pension Contingent orphans If the policy provides a contingent orphans benefit on death of the above named beneficiary please advise if there are potential orphans. If a child s pension is to be paid to an adult an additional authority form will need to be completed. Method of payment Payment details for spouse s/civil partner s/dependant s pension Net of tax to spouse/civil partner/dependant Gross to trustees Section 6 Authority for payment of pension for spouse, civil partner or other dependants This section only needs to be completed if you would like the pension to be paid directly to the spouse/ civil partner. We the trustees of the Group Policy mentioned overleaf, hereby request and authorise Canada Life Limited to act as our agents in paying pensions arising under the said policy on the death of the member named overleaf in the manner described below. Full name Home address Name of bank Branch Bank sort code Account number Roll number (if building society account) Account name 5
Section 7 Checklist Please ensure that all items on this checklist have been enclosed/completed. Failure to do so may delay the claim. Lump sum Claim form fully completed Payment details provided Original death certificate Evidence of earnings Declaration signed Place of work postcode Amount of lump sum For Master Trust only Expression of wish form Pension Please ensure all lump sum boxes are ticked Spouse/dependant bank details (if applicable) Marriage certificate Birth certificate Declaration signed Annual pension amount HMRC annual pension amount Claims will be withheld if any information relating to any aspect of the scheme that we have asked for is outstanding or the premiums we have asked for have not been paid when due. We will not settle any claims, or any requests for additional amounts of benefit, submitted to us more than 2 years after the date of a member s death. Section 8 Declaration Signature To be completed by the trustees or authorised signatories of the scheme. Please provide a list of authorised signatories if it differs from our records. We hereby apply for payment of the benefit(s) described above. We declare that the deceased member was a member of the Scheme on the date of death and that the particulars set out above are correct to the best of our knowledge and belief. We agree that the payment of a benefit in accordance with our instructions above will constitute a full discharge of the liability of Canada Life under the policy in respect of that benefit. Where the benefits claimed include a dependant s benefit, we confirm that the recipient of that benefit was dependant on the member. Date Print name Capacity of signatory* *This signature must be a Trustee or Authorised Signatory. These should be sent as soon as possible to: Life Claims Team, Canada Life Limited, 3 Rivergate, Temple Quay, Bristol BS1 6ER. 0117 916 4460. Our forms are available to download from our website: www.canadalife.co.uk/group Canada Life Limited, registered in England no. 973271. Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA. CLFIS (UK) Limited, registered in England no. 04356028 is an associate company of Canada Life Limited. Registered Office: Canada Life Place, Potters Bar, Hertfordshire EN6 5BA. Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. GRP70 115R Canada Life Limited 3 Rivergate, Temple Quay, Bristol BS1 6ER Telephone 0345 223 8000 6