Retirement Application Form

Important: This form must be submitted to Colleague Info Centre (CIC) sixty (60) days prior to your retirement date.

Section A: Personal Information (please print)

Colleague Last Name First Name (usual) Middle Name

Date of Birth (yyyy.mm.dd) Social Insurance Number

Mailing Address (number, street, province & postal code) Contact information (include area code)
Home Telephone #

Cell Phone #

Alternative #

Email Address:

Section B: Employment Information

Colleague Div-ID#
Date of Hire: Current Employment Status
(refer to your pay statement)

Current Position Title
full-time
part-time
Retirement Date (yyyy.mm.dd)
Last Day of Work (yyyy.mm.dd)
(first day of the month following your last day of work)

Yes No Not Sure Yet

Do you plan to work part-time for Loblaw
Companies Limited after your date of retirement?

Section C: Other required information

Single Married Separated Divorced Widow/er

Common-
Marital Status
Law
Last Name of Spouse/Common-Law partner
(if applicable) First Name Middle Name

Date of Birth (yyyy.mm.dd) Date of Marriage (yyyy.mm.dd) Date of Cohabitation (yyyy.mm.dd)

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)

Please forward completed signed form to:

Colleague Info Centre (CIC), 400 ave Ste-Croix, St-Laurent, Qc, H4N 3L4 | 1-877-303-3013 | Fax 1-888-880-9166 | retired@loblaw.ca
Retirement Application October 2015 Page 1 of 2
 Retirement Application Form (cont.)

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.

Colleague Signature (Required) Date Signed (Required) yyyy.mm.dd

If you need assistance completing this Form please contact

Loblaw Retirement Administration:
Call 1-877-303-3013 or email retired@loblaw.ca

To be completed by CIC administrator:

Date Received (yyyy.mm.dd) Received by: Confirmed Date of Retirement (yyyy.mm.dd)

Pension Options Request Submitted Notification of Intent to Retire (NIR)

Ariel Confirmation: Date: Submitted Date Sent: Sent by:

by:

Please forward completed signed form to:

Colleague Info Centre (CIC), 400 ave Ste-Croix, St-Laurent, Qc, H4N 3L4 | 1-877-303-3013 | Fax 1-888-880-9166 | retired@loblaw.ca
Retirement Application October 2015 Page 2 of 2