F1A Application...F1A Application Client(s) name(s) table of contents Section Description Mandatory...

life and critical illness insurance

A partner you can trust.

www.inalco.com

Application no.

F1A Application

Client(s) name(s)

table of contents

Section Description

Mandatory at all times 1 Proposed insured

2 Purpose of insurance

3 Applicant (if different than proposed insured)

4 Other insurance

Universal Life 5 GENESIS Universal Life

6 TREND Universal Life

7 Confirmation of Identity

Whole life, term and mortgage insurance 8 Traditional Insurance

9 HOME PROTECTION PLAN

Critical illness insurance 10 TRANSITION

11 TRANSITION EVOLUTION

Supplementary income 12 SUPPLEMENTARY INCOME (SI)and additional benefits 13 Additional benefits

Disability 14 Questionnaire for disability coverage

Mandatory at all times 15 Premiums and billing

16 Agent

17 Special instructions

18 Tobacco use

19 Risk class (for life insurance contracts or riders for $200,000 or over)

20 Medical requirements

21 Predeclarations

22 Declaration of insurability

23 Signatures and authorization

24 Authorizations

25 Pre-authorized cheque payments (PAC) agreement

Give to client 26 Pre-notice from the Medical Information Bureau

Give to client if deposit 27 Interim insurance agreement in case of death or critical illness

For use by agent 28 References

Additional documents to provide (if applicable):

Mandatory illustration for GENESIS, TREND and TRANSITION EVOLUTION

Investor profile for TREND: required if the client pays more than the current premium

Investor profile for GENESIS

Q6A questionnaire for disability protection

Q4A questionnaire for critical illness protection

F3A form for an additional insured

F6A or F4A form for a total or partial surrender

Cheque to pay the first premium

proposed insured (for additional insured, please complete f3a) (Write legibly in block letters.)

Application no.

Last and first nameA

1

AddressB

TelephoneC

Date of birth and age at nearest birthday

D

SIN and legal statusE

Occupation (mandatory age 18 and over)

F

Last name First name

Last name at birth (if different)

No. Street Apartment P.O. Box

City Province Postal Code

Home phone no. Work phone no. Extension

Email

Date of birth Age Sex Language

Place of birth (province or country) When did you arrive in Canada?

Social Insurance Number (Mandatory for universal life policy)

Legal status in Canada (for people born outside Canada):

Canadian Citizen

Convention Refugee or Protected Person (attach proof of acceptance as refugee or protected person)

Permanent resident (permanent resident card)

Work permit (work permit card)

Other (letter from Citizenship and Immigration Canada confirming permanent residence application)

If the SIN is not provided on the application, a copy of the proof of legal status must be submitted with the application as shown.

Occupation Since when? Gross annual income

Type of business/Educational institution (For people over age 25 attending an educational institution) Net worth

Current employer’s name and address

Previous occupation for a two-year period

policy no. (for internal use)

D M Y

M Y

Since birth OR

M Y

$

$

M F

English French

Page 1

M Y

To: M Y

From: M Y

To: M Y

From:

Save age.

purpose of insurance

A Personal insurance Business insurance

Key person Estate freeze Buy and sell agreement

Retirement compensation agreement (RCA) Loan Other

B Trial application Complete declarations of insurability, do not order any evidence Heart problems, diabetes, cancer, declined or postponed insurance

C Optional Other application number at Industrial Alliance Additional

2

!

Continued on next page

UNDERWRITING | INDIVIDUAL INSURANCE F1A(13-05)

other insurance

A Does the proposed insured have another insurance application pending? Yes No If yes Date Name of company Amount

Life Critical illness Disability Ins.


this application is optional to the policies listed above Total amount to be placed

B Has the proposed insured ever been declined or had an application modified or postponed? Yes No If yes Reason

Date Name of company


Reason

Date Name of company


C Insurance in force on proposed insured None (group life and credit insurance excluded)

Year

Year

Year

Page 2

Date of birth and SIN

D

OccupationE

Contingent ownerF

D M Y

$

$

M F

M Y

Since birth OR

Date of birth Sex When did you arrive in Canada? Social Insurance Number

Place of birth Relationship to proposed insured Net worth

Present occupation Gross annual income Insurance in force

$

$

$

4

$

3

Last and first name or company’s name

A

AddressB

TelephoneC

applicant (if different from proposed insured)

Last name

First name

No. Street Apartment P.O. Box

City Province Postal code

Home phone no. Work phone no. Extension

for joint insurance, all joint insureds are applicants, unless otherwise indicated below. for a Multilife application, please specify the applicant.

Amount of life

insurance$

Surrender of contract

Amount of critical illness

insurance$

Amount of disability insurance

$Year

of issueContract no.

Industrial Alliance Other companies

Name of company

Will the requested insurance lead to the total or partial surrender of this policy?

Replacement/ disclosure

form attached

Total surrender (F6A)* Partial surrender (F4A-04)*

Yes No


Yes No


Yes No

(mandatory for universal life policy)

*Complete form in parentheses.

Joint insured(s) and/or additional insured(s) – Complete the Addition of Coverage form (F3A).

First to die Last to die

Last to die, paid-up on first to die

GENESIS For Genesis, provide the current version of the complete illustration signed by the client and the information required under the Proceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulations. (F51-208A)

Genesis with performance bonus Genesis with low fees optionIf no instructions are provided, we will use the low fees option.

If low fees option is elected: Without performance stabilizer With performance stabilizer

If no instructions are provided, we will use the option without the stabilizer.

Genesis-IRIS (with low fees option) Individual to joint last-to-die rider (IRIS only)

Permanent Life Coverage Term Life Coverage Rider Critical Illness Term Coverage Rider

$ T10 R & C $ T10 R & C $

T20 R & C $ T20 R & C $

T75 $

T100 $

Automatic Optimization of the Face Amount

Yes NoIf no instruction is given, we will use the AOFA.

Death benefit

Face amount

Face amount + fund

Face amount + guaranteed return of premiums

Face amount + fund + ACB (Available only if the policyowner is a company)

Face amount + fund • No reduction before years (minimum 5 years)

with Wealth Maximizer option

• Floor face amount $ (minimum $1,000)

If no instructions are given, the Wealth Maximizer option is not exercised.

Wealth Maximizer • No reduction before years (minimum 5 years)

• Floor face amount $ (minimum $1,000) If no instructions are given, we will apply 5 years and $1,000.

Cost of insurance

Annual (YRT)

Level – Quick payment option 10 years 15 years 20 years

Level-Investor

On the applicant (complete the Declaration of insurability section.)

Complete the Q4A questionnaire unless a telephone interview or paramedical is required.

Page 3

Levelling of the cost of insurance is planned after years. This is not an automatic option and must be requested by the applicant.

Application no.

5 Genesis universal life (attention – complete beneficiary section on page 7.)

REQuESTED COvERAGE

$ /month $ /month $ /monthContribution in the event of applicant’s disability (CAD)

or CAD = minimum premium

Contribution in the event of applicant’s death (CADE)

or CADE = minimum premium

Contribution in the event of insured’s disability (CID)

If the applicant is a company.

!

!!

!

!

Portion of accumulation fund payable automatically on death of each insured

If no instructions are provided, 100% will be payable.

%

Guaranteed Interest Accounts %

5-year average

6-month term**

1-year term

2-year term*

3-year term*

4-year term*

5-year term*

10-year term*

INvESTMENT ACCOuNTS

Automatic Investment Instructions (AII) (Maximum 10; If no instructions are provided, we will use the Diversified (IA).)Designated Deduction Account (DDA) (Maximum 10; if you want the DDA to be the same as the AII at all times, do not complete this section.)

Page 4

Market Index Accounts Diversified Stategy % % %

Money International Prudent Market Stock Account

European Moderate Bond Stock Account

Canadian U.S. Balanced Stock Stock Account

Global U.S. Growth Stock Stock / DAQ Account

Aggressive Account

Active Management Accounts

% % %

Others

% %

Industrial Alliance Insurance and Financial Services Inc. (hereafter referred to as Industrial Alliance) reserves the right to reimburse deposits at their market value if the contract is refused by the client.* The 2 to 10 year term guaranteed interest accounts are not available in the shuttle fund. For the shuttle fund, these accounts are replaced by the 1 year guaranteed interest account.

**Available with the low fees option only.

AII DDA

AII DDA AII DDA AII DDA

Canadian Stock (Taylor AM)

Canadian Stock (Fidelity)

Canadian Stock (IA)

Canadian Stock (Leon Frazer)

Canadian Stock Small Cap (Fidelity)

U.S. Dividend Growth (IA)

European Stock (Fidelity)

International Stock (Templeton)

Global Stock (Mackenzie Cundill)

Global Stock (IA)

Global Stock (Templeton)

Diversified (Fidelity)

Diversified (IA)

Global Diversified (Aston Hill)

Dividend Growth (IA)

Global Dividend (Dynamic)

Strategic Equity Income (IA)

NorthStar® (Fidelity)

Emerging Markets (Mackenzie Cundill)

Canadian Bond (IA)

Global Health Care (Renaissance)


AII DDA AII DDA

GENESIS

Joint insured on first to die only – Complete the Addition of Coverage form (F3A).Portion of accumulation fund payable automatically on death of each insured _______ %If no instructions are provided, 100% will be payable.

TrENd ! For Trend, provide the current version of the complete illustration signed by the client and the information required under the Proceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulations. (F51-208A).

Permanent Life Coverage Term Life Coverage Rider Critical Illness Term Coverage Rider

T10 R & C

T10 R & C T20 R & C

T20 R & C T75

T100

Automatic Optimisation of the Face Amount (AOFA)

Yes No If no instruction is given, we will use the AOFA.

! On the applicant (complete the Declaration of insurability section)

Page 5

Application no.

6 trend universal life (attention – complete beneficiary section on page 7.)

REQuESTED COvERAGE

!

Complete the Q4A questionnaire unless a telephone interview or paramedical is required.

!

Guaranteed Interest Accounts % % %

5-year average

6-month term*

1-year term

2-year term*

3-year term*

4-year term*

5-year term*

10-year term*


INvESTMENT ACCOuNTSAutomatic Investment Instructions (AII) (Maximum 10; if no instructions are provided, we will use the Portfolio Account.)Designated Deduction Account (DDA) (Maximum 10; if you want the DDA to be the same as the AII at all times, do not complete this section.)

Diversified Strategy Accounts % %

Prudent Account

Moderate Account

Balanced Account

Growth Account

Aggressive Account

Money Market AII DDA AII DDA AII DDA

Market Index Account %

Active Management Accounts % % %

Canadian Bonds (IA)

Tactical Bonds (Aston Hill)

Canadian Balanced (QV)

Diversified (IA)

Dividend Growth (IA)

Global Dividend (Dynamic)

Canadian Stocks (Taylor AM)

Canadian Stocks (Leon Frazer)

Canadian Equity (Small Cap.) (QV)


Others % %

AII DDA AII DDA

Industrial Alliance Insurance and Financial Services Inc. (hereafter referred to as Industrial Alliance) reserves the right to reimburse deposits at their market value if the contract is refused by the client. *The 2 to 10 year term guaranteed interest accounts are not available in the shuttle fund. For the shuttle fund, these accounts are replaced by the 1 year guaranteed interest account.

$ $

$

$

$

$

$

$ /month $ /month $ /monthContribution in the event of applicant’s disability (CAD)

or CAD = current premium

Contribution in the event of applicant’s death (CADE)

or CADE = current premium

Contribution in the event of insured’s disability (CID)

If the applicant is a company.

This page

has

intentionally

been left blank.

BENEFICIARY – LIFE INSuRANCE

Beneficiary 1

Last name First name Sex Date of birth % Relationship to proposed insured

M Revocable F

D M Y

Irrevocable

Contingent beneficiary 1 Sex Contingent beneficiary 2 Sex M Revocable M Revocable

F Irrevocable F IrrevocableBeneficiary 2


M Revocable F

D M Y

Irrevocable




M Revocable F

D M Y

Irrevocable


F Irrevocable F Irrevocable

BENEFICIARY OF THE FuNDS – GENESIS AND TREND

Applicant OR Beneficiary of insured no. 1 OR

Beneficiary 1


M Revocable F

D M Y

Irrevocable




M Revocable F

D M Y

Irrevocable




M Revocable F

D M Y

Irrevocable



GENESIS ANd TrENd

The lack of designation constitutes a revocable designation in favour of the beneficiary or beneficiaries named in the “Beneficiary – Life Insurance” section above.!

The lack of designation constitutes a revocable designation in favour of the applicant.!

Page 7

GENESIS ANd TrENdBENEFICIARY – CRITICAL ILLNESS

Applicant OR Insured OR

Beneficiary 1


M Revocable F

D M Y

Irrevocable

Beneficiary 2


M Revocable F

D M Y

Irrevocable

TRuSTEE*(if beneficiary under age 18) Relationship to proposed insured

* A trustee should be named for any minor beneficiaries or for any beneficiary who cannot give a valid discharge. I name the following person beneficiary to receive benefits payable in the name of any beneficiary who has not reached legal age or who does not have the legal capacity to discharge. This designation is revocable and applies until the beneficiary reaches legal age. IN QuEBEC, THE SOLE DESIGNATION OF A TRuSTEE uSING THIS FORM IS NOT SuFFICIENT TO CREATE A TRuST.

PLEASE CONSuLT YOuR LEGAL ADvISOR ON THIS SuBJECT.

For beneficiary – Last and first name For beneficiary – Last and first name


By law, financial institutions are required to have an anti-money laundering and anti-terrorist financing (“AML/ATF”) program. This form is part of the Company’s AML/ATF program. It is mandatory for non-registered annuity contracts and universal life insurance policies.

1. coMplete this section (Mandatory)

a a. Information about the Applicant/owner (This information must be collected and recorded for every Applicant/owner. If there is more than one Applicant/owner, this information must be collected from each one.)

1. Name of Applicant/owner: _____________________________________________________________________ Date of birth: Y Y Y Y M M D D

Address (not only a P.O. Box Number): _________________________________________________________________________________________________

Principal occupation or business (Be specific. One word generic terms such as “manager”, “consultant” or “president” are not sufficient.):

________________________________________________________________________________________________________________________________

2. Name of Applicant/owner: _____________________________________________________________________ Date of birth: Y Y Y Y M M D D

Address (not only a P.O. Box Number): _________________________________________________________________________________________________

Principal occupation or business (Be specific. One word generic terms such as “manager”, “consultant” or “president” are not sufficient.):

________________________________________________________________________________________________________________________________

Name of payor (if payor is different from the Applicant/owner): __________________________________________________________________________________

Relationship of payor to the Applicant/owner: _______________________________________________________________________________________________

a b. Third Party Determination (If a corporation is the Applicant/owner, neither the corporation, nor the authorized signatory who meets with the life insurance agent to conduct the transaction on behalf of the corporation, is a third party.)

Is the Applicant/owner acting on someone else’s instructions? No Yes (If “yes,” collect the following information.)

Instructions are provided by: an individual a corporation another type of entity (please specify): _____________________________________________

Name: ___________________________________ Date of birth: Y Y Y Y M M D D

Relationship to Applicant/owner: _________________________________________________________________________________________________________

Address (not only a P.O. Box Number): ____________________________________________________________________________________________________

Principal occupation or business (Be specific.): ______________________________________________________________________________________________

If a corporation, provide: Incorporation number: ____________________________ Place of incorporation: ____________________________________________

I cannot determine if the Applicant/owner is acting on someone else’s instructions, but I have reasonable grounds to suspect there is another party involved in this transaction. My reasons are: _________________________________________________________________________________________________________

2. coMplete this section for each individual applicant/oWner (see section 3 for corporations, partnerships, trusts, etc.)

a a. Verification of Identity (Refer to an original passport, driver’s licence or other government-issued identification. SIN card not acceptable.)

Record the following:

1. Type of identification document: ____________________________________________________ Document number: _________________________________

Place of issue: _______________________________________________________________________________ Expiry date: Y Y Y Y M M D D

2. Type of identification document: ____________________________________________________ Document number: _________________________________

Place of issue: _______________________________________________________________________________ Expiry date: Y Y Y Y M M D D

CONFIRMATION OF IDENTITY INFORMATION REQuIRED uNDER THE PROCEEDS OF CRIME (MONEY LAuNDERING)

AND TERRORIST FINANCING ACT AND REGuLATIONS

7 confirMation of identity

a b. Politically Exposed Foreign Persons (PEFPs) (Complete if there is a lump-sum payment of $100,000 or more.) Does the Applicant/owner or payor, or any close relative*, now hold or have they ever held any of the following senior positions in, or on behalf of, a country other

than Canada: No Yes

1. head of state or head of government 2. member of the executive council of government 3. member of a legislature4. deputy minister or equivalent

5. president of a state-owned company or state-owned bank

6. ambassador or attaché or counselor to an ambassador

7. head of a government agency

8. military officer with rank of general or above9. leader or president of a political party represented in

a legislature10. judge

*Note: A close relative of the Applicant/owner or payor means: • mother or father • child • spouse or common-law partner • spouse’s or common-law partner’s mother or father • brother, sister, half-brother, half-sister or any other child of the individual’s mother or father.

! If the above answer is “yes”, then the Applicant/owner or payor is a PEFP and the following must be completed:

If the Applicant/owner or payor holds, or held, one of the positions listed above, provide the following information:

If the Applicant/owner or payor has a close relative who holds, or held, one of the positions listed above, provide the following information about the close relative:

Name of close relative: N/A

Relationship of close relative to Applicant/owner or payor: N/A

Position(s) held (indicate all applicable numbers from list above):

Country where position(s) held:

Dates position(s) held:

Source of funds: Describe the source of funds used for this transaction:

Employment Income Business Income Investments Pension Loan Savings Inheritance

Other (provide details): _________________________________________________________________________

3. coMplete this section for corporate applicants/oWners or other entities

a a. Information about the Applicant/owner

(i) Type of entity: Corporation Partnership Trust Not-for-profit organization Other (Be specific.): ___________________________________

___________________________________________________________________________________________________________________________________

(ii) Record the name, address, and occupation of all persons who own or control, directly or indirectly, 25% or more of the shares of the corporation or 25% or more of the non-corporate entity.

___________________________________________________________________________________________________________________________________

(iii) Record the names and occupations of all directors or trustees. (Please provide a clear description of each director’s/trustee’s occupation.)

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

If the life insurance agent is unable to obtain the information requested in (ii) and (iii) above, state why the information could not be obtained:

___________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________

(iv) Not-for-profit organizations must answer the following:

• Is the Applicant/owner a charity registered with the Canada Revenue Agency? No Yes

• If “no,” does the Applicant/owner solicit charitable financial donations from the public? No Yes

a b. Verify the existence of the corporation or non-corporate entity

Please confirm the existence of the corporation or non-corporate entity by attaching a recent copy (not more than 24 months old) of a certificate of corporate status or any other recent document that confirms the entity’s existence.

a c. Verify the identity of the individual(s) conducting the transaction on behalf of the corporation or non-corporate entity

Refer to an original passport, driver’s licence or other government-issued identification. SIN card not acceptable.

Record the following:

Name: ________________________________________________________________________________________ Date of birth: Y Y Y Y M M D D

Address (not only a P.O. Box Number): ____________________________________________________________________________________________________

Type of identification document: ____________________________________________________________ Document number: ____________________________

Place of issue: __________________________________________________________________________________ Expiry date: Y Y Y Y M M D D

a d. Ensure that the individual(s) conducting this transaction on behalf of a corporation are authorized signatories. If applicable, please attach a resolution of the director(s) confirming that the individual(s) conducting this transaction are authorized signatories of the corporation.

4. life insurance aGent’s confirMation – this confirMation Must be siGned and dated by the life insurance aGent

• As required by the Proceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulations, I confirm that I have verified the identity of the Applicant/owner by reviewing the identification documentation and I have taken reasonable measures to determine if the Applicant/owner is acting on behalf of a third party.

• In cases where there is a lump-sum payment of $100,000 or more for a non-registered annuity contract or universal life insurance policy, I confirm that I have taken reason-able measures to determine if the Applicant/owner and the payor (if not one and the same person) are politically exposed foreign persons.

Name of life insurance agent: ________________________________________________________________________________________________________________

Signature of life insurance agent: X ________________________________________________________________________________ Y Y Y Y M M D D

Application no.

Joint insured(s) and/or additional insured(s) – Complete the Addition of Coverage form (F3A).

First to die Last to die

Last to die, paid-up on first to die

Whole Life Coverage Term Life Coverage Critical Illness Rider

L10 T10 R & C T10 R & C

L15 Ultra T20 R & C T20 R & C

L20 T75

L65 T100

L100

T100

Life and Serenity 65

Child Life & Health Duo

Disability Credit Rider (Please complete Disability Questionnaire in Section 14, questions a), b) and c.)Complete the Q6A questionnaire unless a telephone interview or paramedical exam is required.

Insurance Needs Benefit Chosen Benefit Duration

$

$

$

$

$

$

$

$

The Q9A Preselection questionnaire must be completed.

Complete the Q4A questionnaire unless a telephone interview or paramedical exam is required.

Pick-A-Term

Term

Selected Option: Level

Decreasing to 50%

Decreasing to 0% (only available for terms between 31 and 40 years)


Between 10 and 40 years

2 years 5 years To age 65Min. $300, max. $3,500 without exceeding 1.5%

of the life coverage

As per the Needs Analysis

$ /month $ /month

$

Page 11

REQuESTED COvERAGE8 traditional insurance (complete beneficiary section on page 12.)

9 hoMe protection plan (complete beneficiary section on next page.)

Mortgage insurance

Attach the amortization schedule or complete Q8A form. (The amortization period must not exceed 30 years.)

Life

Critical Illness (Complete the Q4A questionnaire unless a telephone interview or paramedical exam is required.)

Disability 100% Disability 50% (Maximum benefit of $5,000 per month, see the conditions in section 14 d)

Please complete Disability Questionnaire in Section 14.


2 years or until the end of the mortgage (Maximum age 65)

Mortgage Guaranteed Insurability (Must be purchased by both insureds.)

$

$

$

$

$

$

$

!

!

!

!

!

!

!!

TrAdITIONAL INSUrANCE ANd HOME PrOTECTION PLAN

BENEFICIARY – LIFE INSuRANCE

Beneficiary 1


M Revocable F

D M Y

Irrevocable




M Revocable F

D M Y

Irrevocable




M Revocable F

D M Y

Irrevocable



BENEFICIARY – CRITICAL ILLNESS

Applicant OR Insured OR

Beneficiary 1


M Revocable F

D M Y

Irrevocable

Beneficiary 2


M Revocable F

D M Y

Irrevocable







Guaranteed premium critical illness productComplete the Q4A questionnaire unless a telephone interview or paramedical exam is required.

T10 R & C $ T20 R & C $ T75 $ T100 $

Option 10 Option 20 Increased Benefit Rider Return of Premiums upon Death (not available with T20 R&C coverage)

Flexible Return of premiums ➞ Not available with T20 R&C coverage. ➞ For Transition T100, please indicate premium refund period. 15 years 20 years 25 years

Transition Child Complete the F3A Addition of Coverage form and Q4A Questionnaire for each child.

On the applicant (Complete the Declaration of Insurability section.) WPDis for life

For Transition Evolution, provide a complete illustration signed by the client.

Non guaranteed premium critical illness product


Riders and guarantee

Transition Child – Evolution

Complete an addition of coverage form Q3A for each insured child and the Q4A questionnaire.

Increased Benefit Rider

On the applicant (Complete the Declaration of Insurability section.) WPDis for life

$

$

$

Page 13

Application no.

REQuESTED COvERAGE10 transition (complete beneficiary section on pages 13 and 14.)

11 transition – evolution t100 (complete beneficiary section on pages 13 and 14.)

!

!!

!

!

!

!

Applicant or Insured or

Beneficiary 1


M Revocable F

D M Y

Irrevocable




M Revocable F

D M Y

Irrevocable




M Revocable F

D M Y

Irrevocable



BENEFICIARY – CRITICAL ILLNESS

1. Benefits in the event of critical illnessThe lack of designation constitutes a revocable designation in favour of the applicant.!

BENEFICIARY – CRITICAL ILLNESS (Continued)

2. Premium refund upon death (not available with T20 R&C coverage)


M Revocable F

D M Y

Irrevocable


M Revocable F

D M Y

Irrevocable

3. Flexible premium refund during the insured’s lifetime (not available with T20 R&C coverage)

Applicant or Insured

Revocable Irrevocable





$ /month(min. $100, max. $2,000 without

exceeding the eligible benefit, section b))

Employment incomeor net business

and professionalincome

• According to your income tax return;• Pre-tax income (less business overhead expenses, if applicable);• Includes bonuses if they are paid on a regular basis. Excludes interest income, rent, capital gains, retirement income and

any other income that would be paid, if the insured is disabled or not.

$ /month $ /month $ /month $ /month

(Available only as a rider on a life or critical illness insurance contract) Please complete Disability Questionnaire in Section 14, questions a, b and c.

a) Requested benefit • Amount of the SI benefit Complete the Q6A questionnaire unless a telephone interview or paramedical exam is required.

• Type of coverage Accident and illness

Accident only ➞ No benefit is payable for a disability caused by an illness. • Duration of benefit 2 years To age 65

b) Eligible benefit

Monthly employment income Monthly amount of group and/or Eligible or income net of business individual disability insurance benefit and professional income already in force

X 70% = – =

Proof of income will be required in the event of a claim. We recommend that you attach proof of income (income tax return) with the application.

Page 15

REQuESTED COvERAGE12 suppleMentary incoMe (si)

a) Do you work a minimum of 20 hours per week? Yes No If no ➞ Disability Insurance not availableb) Do you work a minimum of 6 months per year? Yes No If no ➞ Disability Insurance not availablec) Have you been working in your current profession for at least 1 year? Yes ➞ Do you work a minimum of 9 months a year? Yes No ➞ Are you a farmer or fisherman? Yes No ➞ 2 year supplemental income accident only offered

No ➞ Do you practice the profession for which you studied? Yes No ➞ 2 year supplemental income accident only offeredd) Home Protection Plan Disability Personal residence ➞ choice of Disability 50% or 100% Owner occupant/residential ➞ 1 – 3 units (Disability 50% or 100%) 4 – 6 units (Disability 50% only)

7 units (Disability not offered)

Non-occupant owner/residential ➞ not available Building housing a business ➞ Occupation of 50% of the area (Disability 50% or 100%) Occupation of less than 50% of the area (Disability not offered)

14 questionnaire for disability coveraGe

Waiver of premiums in case of the applicant’s disability (WPDis)

Waiver of premiums in case of the applicant’s death (WPD)

Waiver of premiums in case of the insured’s disability (WP)

Accidental fracture (AF)

Accidental death (AD) Paramedical Care

Accidental death and dismemberment (AD&D) Hospitalization

Guaranteed insurability (GI) Hospitalization and Home Care

For each child, complete the Addition of Coverage form F3A and, if critical illness is requested, questionnaire Q4A is required.

Child module

Child module PLUS

Child critical illness

$

$

$

$

$

$

13 additional benefits

$

$

!

!

!

!

preMiuMs and billinG

TREND ! Trend’s current premium will be ajusted according to the Current Premium Schedule.

Minimum premium (Genesis) Method of paymentCurrent premium (Trend) Target premium (Genesis et Trend)Modal premium (other products) PAC$ $ ANNUAL

Genesis: Target premium = minimum premium SEMI-ANNUAL*Trend: Target premium = current premium QUARTERLY* Target premium = guaranteed

maximum premium *Not available with Genesis,Trend and Transition

First premium

Deposit by cheque Enclose a cheque payable to Industrial Alliance

Deposit by PAC Attach a cheque specimen to section 25. A withdrawal will automatically be made from the client’s bank account within 3 days for the amount of the minimum or specified premium. Do not enclose a cheque if you choose this option.

COD/PAC – Payment on delivery, amendment to be signed

No deposit will be made while the file is being reviewed.

$

$

Page 16

aGent

15

16

Service agent

Last and first name Code SU %

Agency Code

Work phone no. Extension Cellphone no.

Email

Last and first name Code SU %

Agency Code

Work phone no. Extension Cellphone no.

Email

special instructions17

Agent policy (spouse and children)

risk class for contracts or riders for $200,000 or More of life insurance

If preferred underwriting can be granted

Reduce the premium

Increase the face amount (Additional requirements may be needed.)

If no instructions are given, the premium will be reduced.

Medical requireMents

Will you or your agency order medical requirements?

No

Yes ➞ Name of paramedical organization

Order no.

Preferred language

Special instructions

Requirements dating less than 6 months to be obtained from another company – Name of company

If the amount of insurance is over $2,000,000, have you arranged for the inspection report?

No Yes ➞ Name of Inspection Organization

Special instructions

predeclarations

1

2

3

Page 17

19

20

21

Have you sought medical attention, been diagnosed with, received treatment for or been told you have symptoms of any of the following diseases or disorders? Yes No

If yes, specify

angina/heart attack (myocardial infarction) (with or without bypass surgery/angioplasty) major depression (in the last five years)

cerebral vascular accident (CVA)/transcient ischemic attack bipolar disorder

chronic obstructive pulmonary disease (COPD)/chronic bronchitis/emphysema diabetes

sleep apnea hepatitis

Crohn’s disease cancer/tumor any sites

ulcerative colitis colon polyp

rheumatoid arthritis

Are you being followed for another illness that requires three or more check-ups per year? Yes No

Physician’s full name, address and phone number holding the client’s file (Write legibly in block letters)

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

!

tobacco use18

Have you used any kind of tobacco in the past twelve months including nicotine or tobacco products (gum, patch, etc.)?

YES ➞ Smoker rate

NO ➞ Non-smoker rate Answer the following question. • Have you ever used tobacco? Yes* No

*If yes, when did you quit? M Y

declaration of insurability

For all “Yes” answers, give details below specifying the name of the proposed insured in question. YES NO YES NO

1 Within the past five years, have you consulted a physician, chiropractor or other practitioner, undergone a medical examination or been treated in a hospital, clinic or other medical facility?

If yes, provide Give reason and include medical history that prompted the consultation(s) details and answer Names, addresses and phone numbers of physicians and hospitals consulted Question 2. Consultation dates (frequency)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

2 a) Health problems or follow-up exams (nature of the problem, date of diagnosis, last date)

b) Hospitalizations (duration)

c) Treatment(s) received (type and duration)

d) Medication(s) (name, dosage, duration and date last taken)

e) Diagnostic examination(s) Electrocardiogram(s) X-Ray(s) Blood test(s) (nature, date, results)

Other (specify)___________________________________________________________________________________

f) Follow-up examination(s) recommended (nature and date)

g) Disability or absence from work (cause(s), date and duration)

Details: ______________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

3 Have you consulted or been treated for pain or discomfort in the back, neck or joints (frequency, date, causes)?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

4 Have you tested positive for an AIDS screening test or for Hepatitis B or C? (specify)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

5 Do you have any physical or mental abnormalities? (specify)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Page 18

Applicant with

WPDis, WPD,CAD, CADE

Proposed insured

Optional if paramedical exami nation or phone

interview required

Do not complete declarations of insurability in the following cases:

• Industrial Alliance holds a declaration, a telephone interview or a paramedical exam during the last six months for this insured

• For an additional policy, requirements are generated for the total amount of insurance submitted

22

Application no.

Applicant with

WPDis, WPD,CAD, CADE

declaration of insurability (continued)

13 During the past two years, have you taken part in any hazardous sports such as parachuting, scuba diving, bungee jumping, back-country skiing, heli-skiing, mountain climbing, hang-gliding, gliding, automobile, motorcycle or motocross racing, etc.? (If yes, complete the hazardous sports section in Questionnaire Q1A.)

14 Have you made or do you intend to make aerial flights other than as a passenger? (If yes, complete the aviation section in Questionnaire Q1A.)

15 Within the past five years, have you: (If one of the answers is “Yes”, complete the driving record in Questionnaire Q1A.)

a) been convicted of five infractions or more under the Highway Traffic Act?

b) had your driver’s license suspended or revoked? (If yes, give reason.)

c) been convicted or do you have any charges pending for driving while impaired? (If yes, give dates)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

16 Within the past 10 years, have you used drugs, narcotics or steroids? (If yes, complete the drug section in Questionnaire in Q1A.)

17 Do you or have you ever used alcohol? If yes, answer the following questions: (1 unit = 1 glass of wine = 1 bottle of beer = 1 ounce of alcohol)

a) Current number of units and frequency:

b) If there has been a reduction of alcohol consumption, enter the number of units and frequency before the reduction: (Specify date and reason.)

c) Have you ever received treatment for alcohol use? (dates and name of physician or institution)

d) Have you ever been a member of a support group (such as Alcoholics Anonymous)?

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Proposed insured

Optional if paramedical exami nation or phone

interview required

Page 19

Day Week Month Year

Day Week Month Year

Day Week Month Year

Day Week Month Year

Questions for insured of age 15 and over

YES NO YES NO 6 Do you have symptoms or signs for which you have not yet consulted a physician? (specify)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

7 Do you take medication prescribed by a physician other than those indicated in question 2 d)? (name, dosage, reason)

____________________________________________________________________________________________________

8 Has any family member (father, mother, brother, sister) suffered from or is any family member suffering from diabetes, heart disease, cancer or any other hereditary disease? (Give age at diagnosis, actual age if living or age at death.)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

9 Have you been exposed to the AIDS virus or Hepatitis B or Hepatitis C?

____________________________________________________________________________________________________

10 Have you lost or gained weight by more than 10% in the last year? (If yes, specify the gain or the loss in lbs or kgs and the reason.)

____________________________________________________________________________________________________

11 Height and weight ft cm

lbs kg

12 In the next two years, do you plan to travel or live for more than two months outside Canada or the U.S.? (If yes, complete the foreign residence section in Questionnaire Q1A.)

22

Application no.

This page

has

intentionally

been left blank.

siGnatures and authorization

We, the proposed insured and the applicant, declare that all answers and explanations given in this application, or in any other questionnaire in connection herewith or during any interview, by telephone or otherwise, with respect to our declaration of insurability are true and complete.

We agree that the insurance takes effect as of the acceptance of the application by Industrial Alliance Insurance and Financial Services Inc. inasmuch as the latter has been accepted without modification, the first premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of the applica-tion. We acknowledge that our declaration of insurability may be completed during an interview, by telephone or otherwise, which interview may be recorded, and that Industrial Alliance will rely upon, among other things, the said declaration in determin-ing whether to accept the application.

We hereby authorize any health care professional as well as any other public or private health or social service establishment, any insurance company, the Medical Information Bureau, financial institutions, personal information agents or professional investigation agencies and any public body holding information concerning ourselves or our family, particularly medical information, and any other public or private body holding medical or health-related information concerning ourselves or our family to supply this informa-tion to Industrial Alliance and its reinsurers for the risk assessment or the investigation necessary for the study of any claim.

We also authorize our insurer, or its reinsurers, to exchange with its subsidiaries, its underwriting service providers, and other insurers or financial institutions, the personal information obtained for the purposes of studying this application and to inquire of them for the appraisal of the risk or in the event of a claim, or to exchange with an organization offering medical assistance, personal information for relevant purposes under the insurance coverage in the event of a critical illness. A brief report of information regarding our insurability may be made to the Medical Information Bureau by Industrial Alliance and its reinsurers.

We also authorize Industrial Alliance to release any abnormal test results to our personal physician.

In case of death or disability, the beneficiary, the heir or the liquidator of my estate, is expressly authorized to supply Industrial Alliance, when required by the latter, with all information and authorizations necessary to study the death benefit or disability claim and obtain the required documentation.

We acknowledge having read the interim insurance agreement and having understood the terms thereof.

By signing below, the agent confirms that he has provided a disclosure statement to the applicant which discloses the company or companies he represents and his relation-ship with them; that he receives compensation (such as commissions) for the sale of insurance products and may receive other compensation such as bonuses, invitations to conferences or other incentives; and any conflicts of interest that he may have with respect to this transaction.

We agree that a photocopy of this authorization is as valid as the original.

Page 21

Application no.

23

Signed at this day of

20

Proposed insured (if aged 15 years and over in Quebec, Applicant(s)/Officer’s signature if a company is the If the applicant is a company, provide the names of if aged 16 years and over outside Quebec) applicant the autorized signatories

Agent

The applicant’s signature shall be valid for all additional insureds.

X

X

X

X

X

! The signature of one of the two parents is required for a minor proposed insured if anyone other than the parents is the applicant.

This page

has

intentionally

been left blank.

authorizations24

X

X

X

20

We hereby authorize any health care professional as well as any other public or private health or social service establishment, any insurance company, the Medical Information Bureau, financial institutions, personal information agents or professional investigation agencies and any public holding information concerning ourselves or our family, particularly medical information, and any other public or private body holding medical or health-related information concerning ourselves or our family, to supply this information to Industrial Alliance and its reinsurers for the risk assessment or the investigation necessary for the study of any claim.

A photocopy of this authorization shall be as valid as the original.


Proposed insured (Quebec, age 14 and over; outside Quebec, Witness age 16 and over)

Legal guardian or parent (if insured is not authorized to sign)

X

X

X

20

We hereby authorize any health care professional as well as any other public or private health or social service establishment, any insurance company, the Medical Information Bureau, financial institutions, personal information agents or professional investigation agencies and any public holding information concerning ourselves or our family, particularly medical information, and any other public or private body holding medical or health-related information concerning ourselves or our family, to supply this information to Industrial Alliance and its reinsurers for the risk assessment or the investigation necessary for the study of any claim.

A photocopy of this authorization shall be as valid as the original.


Proposed insured (Quebec, age 14 and over; outside Quebec, Witness age 16 and over)

Legal guardian or parent (if insured is not authorized to sign)

This page

has

intentionally

been left blank.

Each account holder is referred to as “I” in this PAC Agreement section and makes the following statements in respect of himself or herself.

• I authorize Industrial Alliance Insurance and Financial Services Inc. (the “Company”) and the financial institution designated (or any other financial institution I may authorize at any time) to begin deductions as per my instructions for regular recurring payments and/or one-time payments from time to time, for payment of all premiums, deposits, instalments and charges arising from the contract hereunder mentioned. Regular payments will be debited from my specified account based on the date and/or frequency I have chosen, whereas one-time payments from time to time can be debited from my account on any other date.

• I agree that, for the purpose of this PAC Agreement, all PACs from my account will be treated as Personal unless I advise otherwise.

• I waive the right to receive pre-notification of an increase or a decrease in the amount to be debited or a change in the date and/or frequency of these payments.

• I agree that the Company is not required to provide me with written notice of a change in a PAC amount that is made as a result of my request.

• If a PAC is dishonoured for any reason such as, but not limited to, insufficient funds (“NSF”), stop payment or account closed, the Company is authorized to re-submit the payment. Any charges incurred by the Company as a result of the dishonoured PAC will be added to the subsequent PAC.

• I may cancel or modify this PAC Agreement at any time, subject to providing the Company thirty (30) days notice in writing. To obtain a sample cancellation form or for more information on my right to cancel the PAC Agreement, I may contact my financial institution or visit www.cdnpay.ca concerning Rule H1 – Pre-authorized debits (PADs).

• Any cancellation of this PAC Agreement will not affect my insurance contract(s) and/or contract(s) for financial services, so long as payment is provided by an alternate method.

• The Company will not assign this PAC Agreement without providing, any time prior to the next PAC, written notice to me of the assignment.

• I have certain recourse rights if any PAC does not comply with this PAC Agreement. For example, I have the right to receive reimbursement for any PAC that is not authorized or is not consistent with this PAC Agreement. To obtain more information on my recourse rights, I should contact my financial institution or visit www.cdnpay.ca.

Page 25

GENERAL INfoRmATIoN

1. Do you already pay by PAC?

No ➞ (Complete items 3 and 4 and sign.) Yes ➞ (Complete items 2 and 4 and sign.)

2. The premiums must be withdrawn from the same bank account as the one used for the following policy:

! The authorized signatory(ies) must always be the same as the one(s) that authorized the original transaction for which the authorization number had been issued.

3. Banking Information – Attach a personalized specimen cheque; if a specimen cheque is not attached, please complete all the banking information below.

Name of Financial Institution:

Name of Account holder(s):

pre-authorized cheque payMents (pac) aGreeMent

Branch # Institution # Account #

1 2 3 4

1 Cheque number (do not write this number).2 Branch number (5 digits).3 Financial institution number (3 digits).4 Account number. The format may vary from one financial institution to another.

Indicate all numbers and only the numbers.

25

Application no.

General InformatIon (Continued)

4. Withdrawal Arrangement: Variable

PAC category: Personal Business (If both boxes are left unchecked, the PAC category will be considered “Personal”.)

Starting (1st to 28th: if no date is specified, PACs will begin on the effective date of the policy)

Day of withdrawal: Day: _______ (1 to 28)

Same as existing PAC

Issue day

The signature of the account holder(s) and/or the policyowner(s) is required.

! ➞ For a joint account, all required signatories must sign this PAC Agreement. ➞ For a company, the PAC Agreement must be signed by the authorized signatory(ies) and accompanied by a copy of the company’s resolution stipulating the authorized

signatory(ies).

Date:

I confirm that I have all the necessary authorizations from the bank account holder (if other than myself) in order to allow Industrial Alliance to withdraw the premiums from the bank account.

Date:

Y Y Y Y M M D D

XAccount holder’s signature

XAccount holder’s signature, if applicable

XPolicyowner’s signature

XPolicyowner’s signature, if applicable

Y Y Y Y M M D D

Y Y Y Y M M D D

Specimen

Contact Information of service centres:Quebec: Industrial Alliance Insurance and Financial Services Inc., Policyowner Services 1080 Grande Allée West, PO Box 1907, Station Terminus, Quebec City, QC G1K 7M3 Telehone: 418 684-5000, toll-free: 1 800 463-6236, fax: 418 684-5208, email: [email protected]: Industrial Alliance Insurance and Financial Services Inc., Toronto Service Centre, Policyowner Services 522 University Ave., Suite 400, Toronto, ON M5G 1Y7 Telehone: 416 585-8862, toll-free: 1 800 242-9751, fax: 1 877 780-7231, email: [email protected]: Industrial Alliance Insurance and Financial Services Inc., Vancouver Service Centre, Policyowner Services

2165 Broadway West, PO Box 5900, Vancouver, BC V6B 5H6 Telehone: 604 737-9384, toll-free: 1 800 363-2166, fax: 604 739-0534, email: [email protected]

pre-notice froM the Medical inforMation bureau

Information regarding your insurability will be treated as confidential, Industrial Alliance and its reinsurers may, however, make a brief report thereon to the Medical Information Bureau (MIB), a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health coverage, or a claim for benefits is submitted to such a company, the MIB, upon request, will supply such company with the information it may have in its files.

Upon receipt of a request from you, the MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of information in the MIB’s file, you may contact the MIB and request a correction. The address of the MIB’s information office is: Medical Information Bureau, 330 University Avenue, Toronto, Canada, M5G 1R7; telephone: 416 597-0590; www.mib.com.

Industrial Alliance may also release information in its file to other life insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted.

In order to consider your request for insurance, it is possible that we may request additional information.

A representative from an inspection company may contact you to obtain information concerning your personal and financial status. A doctor or registered nurse from a paramedical organization may be asked to complete a medical examination and/or collect a blood or urine sample. The analysis will be used to determine the presence or absence of different abnormalities such as cholesterol, diabetes, hepatic disorders or the use of medication, drugs, nicotine, and infection by the AIDS virus.

Before collecting this blood or urine specimen, your written consent will be required.

The transaction represented by this application is between the applicant and Industrial Alliance. The licensed Agent/Agency soliciting this application is an independent con-tractor representing Industrial Alliance and will receive compensation from Industrial Alliance when the transaction is complete. The applicant is not obligated to transact additional business with the Agent/Agency, Industrial Alliance, or any other organiza-tion as a condition of this application.

In order to offer you insurance, annuity and credit insurance products and other com-plementary services according to your needs, Industrial Alliance will establish a file in which your personal information will be kept.

This file will remain strictly confidential and will be kept in Industrial Alliance’s offices. Only the employees or representatives of Industrial Alliance who need this information as part of their duties, or any other person whom you authorize, will have access to this file.

You are entitled to access the personal information contained in this file and, if neces-sary, to have it rectified by sending a written request to the following address:

Industrial Alliance Insurance and Financial Services Inc. Information Access Officer 1080 Grande Allée West PO Box 1907, Station Terminus Quebec City, QC G1K 7M3

Industrial Alliance may establish a list of its clients for its own commercial prospecting purposes or that of member companies of the Industrial Alliance group. However, you are entitled to have your name removed from this list by making a written request to this effect to the Information Access Officer at the address indicated above.

notice

constitution of a file and protection of personal inforMation

disclosure stateMent

Detach and submit to client

Give to insured

26

This page

has

intentionally

been left blank.

interiM insurance aGreeMent in case of death or critical illness (not applicable to individuals aged under 15 days or over 71 years.)

The interim insurance coverage applies to each proposed insured whose name appears on the application bearing the same number as this agreement, according to the condi-tions hereunder.

The Company offers insurance coverage as of the date the application bearing the same number as this agreement is signed, when an amount equal to 1/12 of the annual premium is paid with the application, including any payment made by enrolling in the PAC mode. The amount will be applied to pay for the policy on the policy issue date.

Life insurance, accidental death, accidental fracture and critical illness coverage requested on the application are payable according to the terms and exclusions of the underwritten policy and the conditions and exclusions hereunder.

MAXIMuM AMOuNT OF INSuRANCE

The maximum coverage for all interim insurance coverages in-force for all applications signed for the same proposed insured is $500,000 including accidental death coverage.

Policy replacement

If the requested insurance replaces a contract of the Company whose face amount is lower than the face amount of the requested insurance, the amount of the interim insur-ance is the difference between the requested face amount on the application and the face amount of the replaced contract.

If the requested insurance replaces a contract of the Company whose face amount is greater than or equal to the face amount of the requested insurance, no amount is pay-able under this interim insurance agreement.

CONDITIONS AND SPECIFIC EXCLuSIONS

This agreement does not include disability, hospitalization or paramedical care cover-ages and changes of insurability that occur before the date the application is accepted other than if death has occurred or a critical illness has been diagnosed.

The Interim insurance is null and void if any of the following cases apply:• If, at the time the application is signed, the proposed insured had consulted or been

treated for the illness which caused his/her death or which led to the diagnosis of a critical illness;

• If the proposed insured had consulted a physician in the 30-day period before the application was signed for a reason other than pregnancy;

• If any answer given on the application, the medical examination report or any other document or process to collect information with regards to the risk is incomplete or false and if a true answer had been given, the application would not have been accepted as requested;

• If the proposed insured is less than 15 days old or more than 71 years old on the nearest birthday when the application is signed;

• specifically for the life insurance coverage, if the proposed insured commits suicide, or dies:- while committing or attempting to commit a criminal offence;- after using drugs or medication otherwise than prescribed by a physician;- while he/she is driving a vehicle with a blood alcohol level higher than

80 milligrams per 100 millilitres of blood;• specifically for the critical illness coverage, if the proposed insured has already

suffered from a covered critical illness or if the diagnosis of a critical illness is cancer or if he/she self-inflicts injuries or he/she does not survive 30 days after the date of the diagnosis.

The death benefit for the Home Protection Plan is not payable if the critical illness benefit is payable.

TERMINATION OF THE INTERIM INSuRANCE AGREEMENT

The interim insurance agreement terminates on the date that the first of the following events occurs:• The application is accepted without modification;• 45 days after the application has been accepted with a modification such as a

change of class, an extra premium, a rate change or a change in the insurance amount;

• The acceptance by the applicant of a policy issued with a modification; • The application is denied by the Company, regardless of whether or not the appli-

cant has been advised;• The cancellation of the application by the applicant;• In all cases, even though the 45-day period mentioned above has not expired,

90 days after the date the application was signed.

The death benefit and critical illness benefit are payable according to the designations made on the application and the accidental fracture benefit is payable to the applicant.

X

20Signed at this day of

Agent

Application no.

Give to applicant if deposit made

27

This page

has

intentionally

been left blank.

referrals

Referrals from the file of

Do you have an RRSP? No Yes Maturity date

D M Y

Do you have mortgage insurance? No Yes Renewal date

1 Last and first name Age Employer

Spouse’s last and first name Age Children’s first names

Address Telephone



Address Telephone



Address Telephone



Address Telephone

Page 31

28

This page

has

intentionally

been left blank.

notes

Consent to Disclosure of Individually Identifying Health Information (Authorized by Section 34 of the Health Information Act)

Please print in ink

I, , authorize (the attached) individually identifying diagnostic, treatment and care information registration information health services provider information

concerning myself to be disclosed by (name of custodian), in accordance with section 34 the Health Information Act, to Industrial Alliance Insurance and Financial Services Inc., for the following purpose(s):

I understand why I have been asked to disclose my individually identifying information, and am aware of the risks or benefits of consenting or refusing to consent to the disclosure of my individually identifying information. I understand that I may revoke this consent at any time.

Dated this of , .

Expiry date (if any) of , .

Source of representative’s authority Client or authorized representative’s signature (If applicable. Ex.: executor, guardian, etc.) (Refer to section 104(1) of the bill.)

Client or authorized representative’s name Witness’ signature Witness’ name

HEAD OFFICE: Industrial Alliance Insurance and Financial Services Inc., 1080 Grande Allée West, PO Box 1907, Station Terminus, Quebec, Quebec G1K 7M3

(day) (month) (year)


The consent forms below must be completed and signed by proposed insureds that reside or have resided in Alberta only. Thanks!

Consent to Disclosure of Individually Identifying Health Information (Authorized by Section 34 of the Health Information Act)

Please print in ink

I, , authorize (the attached) individually identifying diagnostic, treatment and care information registration information health services provider information

concerning myself to be disclosed by (name of custodian), in accordance with section 34 the Health Information Act, to Industrial Alliance Insurance and Financial Services Inc., for the following purpose(s):

I understand why I have been asked to disclose my individually identifying information, and am aware of the risks or benefits of consenting or refusing to consent to the disclosure of my individually identifying information. I understand that I may revoke this consent at any time.

Dated this of , .

Expiry date (if any) of , .

Source of representative’s authority Client or authorized representative’s signature (If applicable. Ex.: executor, guardian, etc.) (Refer to section 104(1) of the bill.)

Client or authorized representative’s name Witness’ signature Witness’ name

HEAD OFFICE: Industrial Alliance Insurance and Financial Services Inc., 1080 Grande Allée West, PO Box 1907, Station Terminus, Quebec, Quebec G1K 7M3



Application

F1A(

13-0

5)The elephant, a symbol of our 120 years of strength and solidity.

Contact Information of the Service Centres:Quebec: Industrial Alliance Insurance and Financial Services Inc. Policyowner Services1080 Grande Allée West PO Box 1907, Station Terminus Quebec City, Quebec G1K 7M3Telephone: 418 684-5000 Toll-free: 1 800 463-6236 Fax: 418 684-5208 Email: [email protected]

Toronto: Industrial Alliance Insurance and Financial Services Inc. Toronto Service Centre Policyowner Services522 University Avenue, Suite 400 Toronto, Ontario M5G 1Y7Telephone: 416 585-8862 Toll-free: 1 800 242-9751 Fax: 416 204-4777 Email: [email protected]

vancouver: Industrial Alliance Insurance and Financial Services Inc. Vancouver Service Centre Policyowner Services2165 Broadway W, PO Box 5900 Vancouver, BC V6B 5H6Telephone: 604 737-9384 Toll-free: 1 800 363-2166 Fax: 604 739-0534 Email: [email protected]

Validate and PrintSave a copyFront pageTable of content1-Proposed Insured *2-Purpose of Insurance *3-Applicant4-Other insurance *5-Universal Life-Investment Accounts-Beneficiary - Life Insurance - Genesis and Trend-Beneficiary of the fund - Genesis and Trend-Beneficiary - Critical Illness - Genesis and Trend

6-Trend Universal Life-Investment Accounts-Beneficiary - Life Insurance-Beneficiary of the fund - Genesis and Trend-Beneficiary - Critical Illness

7-Confirmation of identity8-Traditional Insurance9-Home Protection Plan-Beneficiary - Life Insurance-Beneficiary - Critical Illness

10-Transition11-Transition - Evolution T10012-Supplementary Income13-Additional Benefits14-Questionnaire for Disability Coverage15-Premiums and Billing *16-Agent17-Special Instructions18-Tobacco Use *19-Risk Class for Contracts 200M and more20-Medical Requirements *21-Predeclarations *22-Declaration of Insurability23-Signatures and Authorization *24-Authorizations *25-PAC Agreement26-Pre-Notice from the Medical Information Bureau27-Interim Insurance Agreement in Case of Death or Critical Illness28-ReferencesConsent to Disclosure (Alberta only)Validate and Print

btnValidate: Button1: Button2: Button3: Button4: Button5: Button6: Button7: Button8: Button9: Button10: Button11: Button12: Button13: Button14: Button15: Button16: Button17: Button18: Button19: Button20: Button21: Button22: Button23: Button24: Button25: Button26: S00_chk1: OffS00_chk2: OffS00_chk3: OffS00_chk4: OffS00_chk5: OffS00_chk6: OffS00_chk7: OffS01A_NomNaissance: S01A_Prenom: S01B_Adresse: S01B_Rue: S01B_App: S01B_CasePostale: S01B_Ville: S01B_CodePostal: S01C_TelBureau: S01C_PosteBureau: S01D_DateNaissance: S01D_Age: S01D_Genre: OffS01D_chkConserver: OffS01D_Langue: OffS01D_LieuNaissance: S01D_chkCanada: OffS01D_DateCanada: S01E_NAS: S01E_StatutLegal: OffS01E_StatutLegal_Autre: S01F_Emploi_0: S01F_DateEmploi_0a: S01F_RevenuBrut: S01F_Entreprise: S01F_ValeurNette: S01F_EmployeurNom: S01F_EmployeurAdresse: S01F_Emploi_1: S01F_DateEmploi_1a: S01F_DateEmploi_1b: S01F_Emploi_2: S01F_DateEmploi_2a: S01F_DateEmploi_2b: S02A_Type: OffS02A_chk6_Autre: S02B_chk1: OffS02C_chk1: OffS02C_Proposition: S02C_chk2: OffS03A_Nom: S03A_Prenom: S03B_Adresse: S03B_Rue: S03B_App: S03B_CasePostale: S03B_Ville: S03B_CodePostal: S03C_TelMaison: S03C_TelBureau: S03C_PosteBureau: S03D_DateNaissance: S03D_Genre: OffS03D_chkCanada: OffS03D_DateCanada: S03D_NAS: S03D_LieuNaissance: S03D_Lien: S03D_ValeurNette: S03E_Emploi_0: S03F_Proprietaire: S04A_Suspens: OffS04A_Annee_1: S04A_Nom_1: S04A_Montant_1: S04A_Type_1: OffS04A_Annee_2: S04A_Nom_2: S04A_Montant_2: S04A_Type_2: OffS04A_chk1: OffS04A_Montant_3: S04B_Refus: OffS04B_Raison_1: S04B_Annee_1: S04B_Nom_1: S04B_Type_1: OffS04B_Raison_2: S04B_Annee_2: S04B_Nom_2: S04B_Type_2: OffS04C_chkAucune: OffS04C_chk1_1: OffS04C_chk2_1: OffS04C_Compagnie_1: S04C_Resiliation_1: OffS04C_Montant1_1: S04C_Montant2_1: S04C_Montant3_1: S04C_Annee_1: S04C_chk3_1: OffS04C_Contrat_2: S04C_chk1_2: OffS04C_chk2_2: OffS04C_Compagnie_2: S04C_Resiliation_2: OffS04C_Montant1_2: S04C_Montant2_2: S04C_Montant3_2: S04C_Annee_2: S04C_chk3_2: OffS04C_chk1_3: OffS04C_chk2_3: OffS04C_Compagnie_3: S04C_Resiliation_3: OffS04C_Montant1_3: S04C_Montant2_3: S04C_Montant3_3: S04C_Annee_3: S04C_chk3_3: OffS05B_Version: OffS05B_Stabilisateur: OffS05C_Montant_1: S05C_Montant_2: S05C_Montant_3: S05C_Montant_4: S05C_Montant_5: S05D_Optimisation: OffS05E: OffS05E_Ans_1: S05E_Ans_2: S05E_Montant_2: S05F: OffS05F_Ans: S05F_Option: OffS05G_Montant_1: S05G_chk1: OffS05G_Montant_2: S05G_chk2: OffS05G_Montant_3: S05H_DIA_1: S05H_DDA_1: S05H_DIA_2: S05H_DDA_2: S05H_DIA_3: S05H_DDA_3: S05H_DIA_4: S05H_DDA_4: S05H_DIA_5: S05H_DDA_5: S05H_DIA_6: S05H_DDA_6: S05H_DIA_7: S05H_DDA_7: S05H_DIA_8: S05H_DDA_8: S05H_DIA_9: S05H_DDA_9: S05H_DIA_10: S05H_DDA_10: S05H_DIA_11: S05H_DDA_11: S05H_DIA_12: S05H_DDA_12: S05H_DIA_13: S05H_DDA_13: S05H_DIA_14: S05H_DDA_14: S05H_DIA_15: S05H_DDA_15: S05H_DIA_16: S05H_DDA_16: S05H_DIA_17: S05H_DDA_17: S05H_DIA_18: S05H_DDA_18: S05H_DIA_19: S05H_DDA_19: S05H_DIA_20: S05H_DDA_20: S05H_DIA_21: S05H_DDA_21: S05H_DIA_22: S05H_DDA_22: S05H_DIA_23: S05H_DDA_23: S05H_DIA_24: S05H_DDA_24: S05H_DIA_25: S05H_DDA_25: S05H_DIA_26: S05H_DDA_26: S05H_DIA_27: S05H_DDA_27: S05H_DIA_28: S05H_DDA_28: S05H_DIA_29: S05H_DDA_29: S05H_DIA_30: S05H_DDA_30: S05H_DIA_31: S05H_DDA_31: S05H_DIA_32: S05H_DDA_32: S05H_DIA_33: S05H_DDA_33: S05H_DIA_34: S05H_DDA_34: S05H_DIA_35: S05H_DDA_35: S05H_DIA_36: S05H_DDA_36: S05H_DIA_37: S05H_DDA_37: S05H_DIA_38: S05H_DDA_38: S05H_DIA_39: S05H_DDA_39: S05H_DIA_40: S05H_DDA_40: S05H_DIA_41: S05H_DDA_41: S05H_DIA_42: S05H_DDA_42: S05H_Autre_43: S05H_DIA_43: S05H_DDA_43: S05H_Autre_44: S05H_DIA_44: S05H_DDA_44: S05H_DIA_45: S05H_DDA_45: S05H_Autre_46: S05H_DIA_46: S05H_DDA_46: S061B: OffS061B_Directive: OffS061B_Directive_Autre: S061B_Nom: S061B_Date: S061B_Lien: S061B_Adresse: S061B_Profession: S061B_Numero: S061B_Lieu: S061B_chk: OffS061B_Motifs_1: S063A_nom_1: S063A_nom_2: S063A_nom_3: S063A_nom_4: S063A_1: OffS063A_2: OffS063C_1: S063C_Date_1: S063C_2: S063C_3: S063C_4: S063C_5: S063C_Date_2: S064_Repr: S064_Date: 2013-04-29S7_1: S7_2: S7_3: S7_4: S7_5: S7_6: S7_7: S7_8: S7_9: S7_10: S7_11: S7_11_Terme: S7_11_Option: OffS7_12: S7_13: S8_1: S8_chk_1: OffS8_chk_2: OffS8_Invalidite: OffS8_Invalidite_1: OffS8_chk_3: OffS09_1: S09_2: S09_chk_1: OffS09_chk_2: OffS09_chk_3: OffS09_Option: OffS09_chk_4: OffS11_Main: OfftxtS11_Main: Please check to activate section 12S11_1: S11_Type: OffS11_Duree: OffS11_2: S11_3: S11_4: S11_5: S12_Main: OfftxtS12_Main: Please check to activate section 13S12_chk1: OffS12_chk2: OffS12_chk3: OffS12_chk4: OffS12_chk5: OffS12_1: S12_chk6: OffS12_2: S12_chk7: OffS12_3: S12_chk8: OffS12_chk9: OffS12_4: S12_chk10: OffS12_5: S12_chk11: OffS12_6: S12_chk12: OffS12_7: S12_chk13: OffS12_8: S13_Main: OfftxtS13_Main: Please check to activate section 14S13a: OffS13b: OffS13c: OffS13c1: OffS13c12: OffS13c2: OffS13_chk1: OffS13_chk2: OffS13d2: OffS13_chk3: OffS13_chk4: OffS13d4: OffButton28: S14_Prime: OffS15_chk: OffS15_Nom_1: S15_Code_Agent_1: S15_US_1: S15_Perc_1: S15_Agence_1: S15_Code_Agence_1: S15_Telephone_1: S15_Poste_1: S15_Cell_1: S15_Courriel_1: S15_Nom_2: S15_Code_Agent_2: S15_US_2: S15_Perc_2: S15_Agence_2: S15_Code_Agence_2: S15_Telephone_2: S15_Poste_2: S15_Cell_2: S15_Courriel_2: S16_1: S16_2: S16_3: S16_4: S16_5: S16_6: S17_1: OffS17_2: OffS17_Date: S18_1: OffS19_1: OffS19_Nom: S19_Numero: S19_Langue: S19_Instructions: S19_chk: OffS19_Compagnie: S19_2: OffS19_Organisme: S19_Instructions_2: S20_1: OffS20_chk1: OffS20_chk2: OffS20_chk3: OffS20_chk4: OffS20_chk5: OffS20_chk6: OffS20_chk7: OffS20_chk8: OffS20_chk9: OffS20_chk10: OffS20_chk11: OffS20_chk12: OffS20_chk13: OffS20_2: OffS20_Medecin_1: S20_Medecin_2: S21_1: OffS21_1b: OffS21_1_1: S21_1_2: S21_1_3: S21_1_4: S21_1_5: S21_1_6: S21_2a: OffS21_2ab: OffS21_2b: OffS21_2bb: OffS21_2c: OffS21_2cb: OffS21_2d: OffS21_2db: OffS21_2_chk_1: OffS21_2_chk_2: OffS21_2_chk_3: OffS21_2_chk_4: OffS21_2_chk_5: OffS21_2_Autre: S21_2e: OffS21_2eb: OffS21_2f: OffS21_2fb: OffS21_2g: OffS21_2gb: OffS21_2_1: S21_2_2: S21_2_3: S21_2_4: S21_2_5: S21_2_6: S21_2_7: S21_2_8: S21_2_9: S21_3: OffS21_3b: OffS21_3_1: S21_3_2: S21_4: OffS21_4b: OffS21_4_1: S21_4_2: S21_5: OffS21_5b: OffS21_6: OffS21_6b: OffS21_6_1: S21_6_2: S21_7: OffS21_7b: OffS21_7_1: S21_8: OffS21_8b: OffS21_8_1: S21_8_2: S21_9: OffS21_9b: OffS21_9_1: S21_10: OffS21_10b: OffS21_10_1: S21_11_taille: OffS21_11_1: S21_11_1b: S21_11_poids: OffS21_11_2: S21_11_2b: S21_12: OffS21_12b: OffS21_13: OffS21_13b: OffS21_14: OffS21_14b: OffS21_15a: OffS21_15ab: OffS21_15b: OffS21_15bb: OffS21_15c: OffS21_15cb: OffS21_15_2: S21_16: OffS21_16b: OffS21_17o: OffS21_17ob: OffS21_17a: S21_17_freqa: OffS21_17ab: S21_17_freqab: OffS21_17b: S21_17_freqb: OffS21_17_freqbb: OffS21_17c: OffS21_17cb: OffS21_17d: OffS21_17db: OffS21_17_1: S21_17_2: S21_17_3: S22_Sig_Jour: S22_Sig_Mois: [[None]]S22_Sig_An: S23_Sig_Lieu: S23_Sig_Jour: S23_Sig_Mois: [[None]]S23_Sig_An: F02_1_PAC: OffF02_4_Categ: OffF02_4_JourType: OffF02_4_Jours: [[None]]F02_Date_1: 20130429F02_Date_2: 20130429S26_Sig_Lieu: S26_Sig_Jour: S26_Sig_An: S27_Dossier: S27_Reer: OffS27_Echeance: S27_Hyp: OffS27_Renouvellement: S27_1_1: S27_1_2: S27_1_3: S

Date post:	27-Jan-2021
Category:	Documents
Upload:	others
View:	4 times
Download:	0 times

F1A Application...F1A Application Client(s) name(s) table of contents Section Description Mandatory...

Documents