Supplementary Life Insurance –Enrolment Form

ALL SECTIONS MUST BE COMPLETED. INCOMPLETE OR FAXED FORMS WILL NOT BE PROCESSED.
PLEASE PRINT IN BLOCK LETTERS AND COMPLETE IN INK
IMPORTANT
New applicant If you apply more than 31 days following your date of hire, or if you want to increase your coverage, you will be
required to complete and submit an Evidence of Insurability Form (ACF866CAN-2) directly to Manulife. In order
Change in coverage to obtain dependent coverage, the employee must purchase at least $10,000 of coverage.
Is your Evidence of Insurability completed? Yes No N/A
Beneficiary Change No need to complete additional document
1. Employee Identification
Employee Number Date of Birth (YYYY/MM/DD) Employee province or state of residence

Family (Last Name) First Name Middle Name

2. Beneficiary’s identification – If a beneficiary is not assigned “ESTATE” will be assumed

Family (Last) Name First Name Beneficiary’s Relationship

For Quebec residents only

Note:
In Quebec, the designation of your spouse as beneficiary is irrevocable unless
If beneficiary is shown as irrevocable, his/her consent is required to
otherwise specified.
change it. Include a signed and dated consent with this form. You are
If spouse is beneficiary, designation is:
responsible for ensuring the validity of your designation.
Revocable Irrevocable
3. I wish to be insured for the following coverage (in dollars). Check only one box
(Note: Retirees are limited to $50,000 of coverage only)
10,000 20,000 30,000 40,000 50,000
60,000 70,000 80,000 90,000 100,000
110,000 120,000 130,000 140,000 150,000
160,000 170,000 180,000 190,000 200,000
210,000 220,000 230,000 240,000 250,000
260,000 270,000 280,000 290,000 300,000
310,000 320,000 330,000 340,000 350,000
360,000 370,000 380,000 390,000 400,000
4. I wish to insure my eligible dependents for life benefits (in dollars):
On box must be selected Spouse Children Spouse and Children
Note: Retirees age 65 and over are limited to 1 unit of coverage only - 5,000
Please select coverage amount below:
Spouse Children Spouse Children Spouse Children Spouse Children

5,000 2,500 10,000 5,000 15,000 7,500 20,000 10,000

25,000 12,500 30,000 15,000 35,000 17,500 40,000 20,000
45,000 22,500 50,000 25,000 55,000 27,500 60,000 30,000
65,000 32,500 70,000 35,000 75,000 37,500 80,000 40,000
85,000 42,500 90,000 45,000 95,000 47,500 100,000 50,000
5. Employee Signature
I hereby apply for insurance under the supplementary life insurance plan and authorize the deduction from my pay
for any contributions I must make toward the cost of these benefits

Employee Signature Date

6. Reserved for HR Connex Centre
Employee date of hire (YYYY/MM/DD) Late application Active
Yes No Retired
Signature Date

Please send this form duly filled to the Air Canada Group Benefits via the following channel :
Air Canada Centre – YUL 1265, P.O. Box 14000 – Station Airport, Dorval, Quebec H4Y 1H4

ACF866-1A (2016-02)