Information About Requestor

(Policyholder or Super Administrator)

Language preference*


Information About Access Request
You would like to...*

Appointed person

Language preference*

Administrator profile granted *

Simply place your cursor over the Administrator's profile to read the definition.

Access rights

The person appointed acts as , based on this request, for the group(s) and employer(s) indicated below.

Error(s) line 1:

Error(s) line 2:

Error(s) line 3:

Error(s) line 4:

To enter an access request, click on the Add button. You can then fill out another access request on the same form.

Signature of Requestor

(Policyholder or Super Administrator)

The Policyholder and the Super Administrator are responsible for communicating any changes by submitting this form. Furthermore, only requests made by submitting this form are accepted.

For any online application or request for change form completed on La Capitale's website, the Policyholder and the Super Administrator are also in charge of:

  • Having all hard copies signed by the participant;
  • Keeping such copies in a safe place and ensuring their confidentiality;
  • Providing the original of any completed and signed form kept in their files within three working days, upon La Capitale's request.

The Policyholder's signature is mandatory in order to appoint a Super Administrator and to grant a broker access rights.

The Super Administrator's signature is mandatory in order to appoint a person other than a Super Administrator.