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SELECTPAC GROUP INSURANCE ADJUSTMENTS TO THE GREAT-WEST LIFE ASSURANCE COMPANY PO BOX 6000 WINNIPEG MANITOBA R3C 3A5 FAX 204 946-8972 EMPLOYEE NAME PREPARE IN DUPLICATE - ORIGINAL TO GWL - RETAIN DUPLICATE CLEAR I. D. NUMBER When Known POLICY NO DIV. NO. DATE Please Print COMPLETED BY AREA CODE PHONE REASON CODE See Below PLEASE INCLUDE DETAILS EFFECTIVE DATE OF CHANGE S REASON CODES Please insert the applicable Reason Code for each employee in .

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