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Important: This form must be submitted to Colleague Info Centre (CIC) sixty (60) days prior to your retirement date.
Mailing Address (number, street, province & postal code) Contact information (include area code)
Home Telephone #
Cell Phone #
Alternative #
Email Address:
full-time
part-time
Retirement Date (yyyy.mm.dd)
Current Position Title Last Day of Work (yyyy.mm.dd)
(first day of the month following your last day of work)
Section D: Authorization
By my signature below I confirm my decision to retire from Loblaw Companies Limited on the date specified above. I request that
on receipt of this signed Form, Loblaw Retirement Administration proceed to process my application for retirement.
I understand and agree that should I decide to withdraw my retirement application I must notify Loblaw Retirement
Administration in writing. I further acknowledge and agree that my Retirement Application Form will be processed unless
written, signed notification to withdraw my application has been received by Loblaw Retirement Administration.
__________________________________________________ _________________________________________________
Colleague Signature Date (yyyy.mm.dd)
Consent
I understand that the personal information provided herein as well as any other personal information currently held or collected
in the future by the Company or the underwriter of my group benefits and/or pension program may be collected, used, or
disclosed to administer the group policy and/or pension plan of which I am an eligible member, to develop and recommend
suitable products and services to me.
Depending on the type of coverage I carry and/or pension plan that I have, the personal information provided above and limited
other medical information may be collected from and/or released to a third party. These third parties include other underwriters,
health care professionals or institutions, health and life insurers, pension plan administrators, government and regulatory
authorities, and other third parties when required to administer the benefits outlined in the group policy and/or pension plan of
which I am an eligible member.
I understand that my personal information will be kept confidential and secure. I understand that I may revoke my consent at any
time. However, if consent is withheld or revoked, the coverage may be denied or rescinded. I understand why my personal
information is needed and am aware of the risks and benefits of consenting or refusing to consent to its collection, use and
disclosure. For additional information regarding the underwriters of the Company's privacy policies, I can contact them regarding
the collection, use or disclosure of my personal information.
I authorize the underwriter of my group benefits and/or the administrators of my pension plan to collect, use and disclose my
personal information as described above. I declare that the statements I have made are complete and true and that any false
information may result to denial or termination of benefits.