DISCLOSURE FORM AND INDEMNITY AGREEMENT
I, ______________________ (Name of Applicant), have applied for a commutation and surrender of
policy number _____________________ (the “Policy”) issued by The Canada Life Assurance
Company (the “Company”) pursuant to the provisions of the Pension Benefits Act, 1992 (Saskatchewan)
as amended (the “Act”), and the regulations thereto. I have determined, to the best of my ability, that
pursuant to the said provisions and regulations, this application qualifies for acceptance by the Company,
and therefore the Policy may be commuted and surrendered.
I acknowledge that the said commutation and surrender is only possible in prescribed circumstances, and
that the Company must rely on the information and representations made herein to determine, for itself,
whether or not this application qualifies for acceptance, and therefore whether or not the Policy may be
commuted and surrendered.
As a result, I hereby certify that: (i) I have diligently searched my records, (ii) I have made any inquiries
necessary to ensure the completeness of my records, and (iii) the information contained in this form is
true, complete and accurate, to the best of my knowledge and belief.
In recognition that, in proceeding with my application, the Company must rely upon the truth,
completeness and accuracy of the information contained in this form, I agree that I will indemnify and
hold the Company harmless with respect to any and all claims and/or demands by any party, including
any and all associated costs, expenses, damages and/or liability incurred by or attributed to the Company,
where such arise, directly or indirectly, out of or as a result of reliance by the Company upon this
information, and/or the commutation and surrender of the Policy.
For valuable consideration, the receipt of which is hereby acknowledged, and following the commutation
and surrender of the Policy, I, for myself, my heirs, successors and assigns also release and forever
discharge the Company from any and all claims or obligations arising under the provisions of the Policy.
I certify that I do not hold any locked-in pension credits or funds other than those represented by the
Policy, and specifically, I do not hold any other Locked-in Registered Retirement Savings Policies
(Locked-in RRSPs), Locked-in Retirement Accounts (LIRAs), Life Income Funds (LIFs), Locked-in
Retirement Income Funds (LRIFs) or other such products whether with the Company or with any other
financial institution, including any insurance company, bank, savings institution or trust company.
February 2004 Page 1
Signed at _______________________ this _________ day of __________________ ,
(City and Province) (Day of Month) (Month) (Year)
(Signature of Witness) (Signature of Applicant)
(Print Name of Witness)
February 2004 Page 2