Instructions for Life Insurance Claim

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1 Instructions for Life Insurance Claim Instructions for Claimant 1. Please complete the Claimant's Statement for Group Creditor Life Insurance. Besuretosignand date all entries. Include your phone number. Complete and sign the authorization at the bottom of the form Date and sign Section 1 and have the physician complete Section 2 of the Attending Physician's Statement-ProofofDeath. Provide the name and address of the deceased's family physician, if the form is completed by a different physician. Retain a copy of the completed claim form for your records. Take the original, completed form to the branch. The branch staff will submit the completed claim to us via courier. If you wish, you may submit the claim documents along with the completed branch statement directly to TD Life Insurance Company, at the address listed below. Branch Instructions Complete the Claim for Group Creditor Life Insurance. Attach a copy of the application for insurance if available. Be sure to enter the branch transit number, address, telephone number and name of contact person, should it be necessary for the claims department to contact you. 4. Send the completed claim package to: TD Life Insurance Company Richmond Adelaide Centre 120 Adelaide Street West, 2nd Floor Toronto, Ontario M5H 1T1 If you have any questions about completing the form please contact us at

2 Claim for Group Creditor Life Insurance Statement of Claim (Completed by Branch) Product: Mortgage Line of Credit Loan Insurer: Canada Life Prudential CT Financial Assurance Branch/Transit Number: Mtg/LOC/Loan Number: Please provide details of any other credit insured mortgages, lines of credit or loans held by the deceased at this financial institution. Name of Deceased: (Last Name) (First Name and Initial) (City) (Province) (Postal Code) Date of Death: Principal Balance at Date of Death Date of Last Regular Payment Per Diem/Daily Rate at Date of Death Insurance Effective Date Date Funds Advanced Initial Loan/Mortgage Amount, or Line of Credit Limit Refinancing Details Yes No Remarks: Branch Contact: Signature: Title: Telephone Number: ( ) -

3 Claimant's Statement for GroupCreditorLifeInsurance Statement of Claim (Completed by Claimant) Section 1 - Statement of Next-of-Kin or Deceased's Representative Name of Deceased: (Last Name) (First Name and Initial) (City) (Province) (Postal Code) Name and Address of Family Physician of Deceased: Date of Death: Other physicians consulted during the last 24 months, hospitals and institutions attended. Physician, Hospital, Institution Address Nature of Illness or Injury Dates Insured's Occupation at Date of Death: Name and Address of Employer: Other Life Insurance in force with this or other Companies. Company Effective Date Face Amount Name of Next-of-Kin: Relationship to Deceased: (City) (Province) (Postal Code) Telephone Number ( ) - Signature: This claim form can be used for otherwise valid claims under discontinued policies. Section 2 - Life Claim Authorization (0303) Insurer: Prudential Canada Life Claimant's authorization: regarding the death of CT Financial Assurance (may be completed by the administrator) (the "Life Insured") I hereby authorize and request any physician, hospital, clinic, individual, law enforcement or government organization, insurance company, or other entity that has any personal and medical records, information or knowledge (including findings pertaining to the death) in regard to the Life Insured, to release and provide full details (including furnishing copies) of all available personal and medical information records and knowledge, including prior medical history, autopsy, toxicological or pathological findings which they may possess to the above noted insurer in regard to this claim, its authorized administrator, TD Life Insurance Company, its re-insurers or their respective agents. Thisinformationistobeusedintheevaluationofaninsuranceclaimandforpurposesrelatingtosuchclaim.Thisconsentshallbe valid during the continuation of such claim. I also authorize my insurer, its authorized administrator, TD Life, its reinsurers and their respective agents to exchange and/or transmit information concerning this claim to the organizations listed above as is necessary to evaluate this claim. Signed at Date Print name of Claimant Relationship of Claimant to Deceased Signature of Claimant Print Name of Executor or Administrator Address of Executor or Administrator Signature of Executor or Administrator A photocopy / fax of this authorization shall be as valid as the original

4 AttendingPhysician'sStatement-ProofofDeath Section 1 - Claimant's Declaration Branch and Account Number I hereby authorize the release of any information requested in respect of this claim, to my insurer and its authorized claims administrator, TD Life Insurance Company. Date Signature of Next-of-Kin or Deceased's Representative The claimant is responsible for the securing of this form and any charge which may be made for its completion. Section 2 - Attending Physician's Statement (Completed by Physician) Full Name of Deceased Date of Birth, or Age at Death Date of Death Place of Death Cause of Death (Enter one cause for each of (a), (b) and (c)) Disease or condition directly leading to death. (a) Antecedent causes (Morbid conditions, if any, giving rise to the above cause (a), stating the underlying cause last) Due to (b) Due to (c) Interval Between Onset and Death (a) (b) (c) Date of diagnosis of illness leading to death If death was due to an accident, suicide or homicide, state which and provide a brief description of the circumstances Date of first attendance in final illness Date of last attendance in final illness Name and Address of Family Physician (continued) If you wish, you may mail this form to the administrator at the address below: TD Life Insurance Company, Richmond Adelaide Centre, 120 Adelaide Street West, 2nd Floor Toronto, Ontario M5H 1T1. Tel :

5 Did the deceased, to your knowledge, receive treatment during the last 3 years from you or any other physician, or in any hospital or institution? (If "Yes", please provide the following information) Yes No Physician, Hospital, Institution Address Nature of Illness or Injury Dates Declaration: These statements are true and complete to the best of my knowledge and belief. Physician's Signature: Specialty: Name: Telephone Number: ( ) - Fax Number: ( ) -

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