Request for Change by jennyyingdi

VIEWS: 10 PAGES: 26

									LIFE AND CRITICAL
ILLNESS INSURANCE




 F4A Request for Change




A partner you can trust.


www.inalco.com   www.iapacific.com
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INSTRUCTIONS

• The MANDATORY INFORMATION and SIGNATURES sections must be completed for each submitted page of the form.
• Please note that if the policyowner is a company, the president’s signature is mandatory.
• Each page of this request for change form must be used for one policy only, except for section 2 of page F4A-01.
• You must submit only the page(s) of this form which applies to the change(s) requested.
• Please provide your client with the F4A-17 of this form, if applicable.
• Please refer to the wording of the policy for the applicable conditions for each product.

TABLE OF CONTENTS



 F4A          Section      Request for Change
 F4A-01          1         Mode of Payment --> GoTo
                 2         Existing Pre-Authorized Cheque (PAC) Payments --> GoTo
                 3         Target Premium (Universal Life Policy) --> GoTo
 F4A-02          4         Pre-Authorized Cheque (PAC) Agreement --> GoTo
 F4A-03          5         Addition of Coverage and/or Additional Benefits --> GoTo
                 6         Addition of 10-15-20 Option (Universal Life Policy) --> GoTo
 F4A-04          7         Cancellation/Reduction of Coverage and/or Additional Benefits --> GoTo
 F4A-05          8         Reinstatement/Policy Not placed --> GoTo
 F4A-06          9         Tobacco Status (Change to Non-Smoker) --> GoTo
 F4A-07         10         Risk Class (Change to Preferred/Elite) --> GoTo
 F4A-08         11         Extra Premium/Exclusion (Revision) --> GoTo
                12         YRT to Level Cost of Insurance (Universal Life Policy) --> GoTo
 F4A-09         13         Death Benefit (Universal Life Policy) --> GoTo
                14         Reduced Paid-Up Policy --> GoTo
 F4A-10         15         Change in Type of Plan --> GoTo
 F4A-11         16         Duplicate Policy --> GoTo
                17         Date of Birth (Correction) --> GoTo
 F4A-12         18         Exercise the Guaranteed Insurability Benefit (GI) --> GoTo
 F4A-13         19         Conversion --> GoTo
 F4A-14         20         Dissociation --> GoTo
 F4A-15         21         Dissolution of a Joint 1st to Die Coverage --> GoTo
                22         Withdrawal of an Insured on a Joint 1st to Die Coverage --> GoTo
 F4A-16         23         Association --> GoTo
 F4A-17         24         Interim Insurance Agreement in the Event of Death or Critical Illness --> Goto
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                                                                   Request for Change                        • MODE OF PAYMENT                                                                                         F4A-01
                                                                         Life and Critical
                                                                                                             • EXISTING PRE-AUTHORIZED CHEQUE (PAC) PAYMENTS
                                                                        Illness Insurance
                                                                                                             • TARGET PREMIUM (UNIVERSAL LIFE POLICY)
MANDATORY INFORMATION
Agency                                                             Agency Code            Agent                                                                               Agent code
                                                                                                                                                                                                                              SU




                                                                   Principal insured’s last and first name                                                                                            Amount received
Policy no.

              -                                      -                                                                                                                                                $
                                                                                                                                                              Date (yyyy-mm-dd)                                    Initials
                                                                                                                              Reserved for H.O.
                  Please check
1.                 MODE OF PAYMENT

Warning: The Semi-annual and Quarterly frequencies of payment are not available for Universal Life, Transition, Alternative and Perspective policies.

1.1 Change frequency of payment to:

             Annual              •   Is it a traditional policy?               Yes ➡ Attach a cheque for the premiums due in accordance with the new frequency of payment chosen.
                             ▲




             Semi-annual         •   Is it a universal life policy?            Yes ➡ Attach a cheque for the premiums due in accordance with the new frequency of payment chosen,
             Quarterly                                                               unless there are enough funds in the policy.

             Monthly Pre-Authorized Cheque (PAC) Payments
             ➡ Complete the Pre-Authorized Cheque (PAC) Agreement on the F4A-02.                                                                                                          Y   Y   Y    Y       M   M    D     D
1.2 Loan reimbursement by pre-authorized cheque (PAC) payments of $_________________ to be added to the regular premium starting                                                                                                   .
    ➡ Complete the Pre-Authorized Cheque (PAC) Agreement on the F4A-02 if the current mode of payment is other than PAC.
                  Please check
2.                 EXISTING PRE-AUTHORIZED CHEQUE (PAC) PAYMENTS

2.1          Section     A   Enter all policy numbers affected by these changes:


                                           -                                          -                           -                                                            -


                                           -                                          -                           -                                                            -


                                           -                                          -                           -                                                            -

                         B       Change withdrawal date for the policy(ies) indicated in section A (day 1 to 28 only): _______.
                         C       Change the banking information for the policy(ies) indicated in section A.
                                 ➡ Complete the Pre-Authorized Cheque (PAC) Agreement on the F4A-02.
                         D       Restart the pre-authorized cheque (PAC) payments which are presently stopped.
                  Please check
3.                 TARGET PREMIUM (UNIVERSAL LIFE POLICY)
                                                                                                                                                      Y       Y       Y       Y       M       M   D        D
3.1 Choose ONE of the following three options:                Change the target premium to $ __________________ starting
                                                         OR                                                           Y       Y       Y       Y       M       M       D       D
                                                              Target premium = minimum premium starting
                                                         OR                                                               Y       Y       Y       Y       M       M       D       D
                                                              Target premium = monthly cost + taxes starting

DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
                                     SEE OVERLEAF FOR SIGNATURE ON PRE-AUTHORIZED CHEQUE PAYMENTS (PAC) AGREEMENT.
                                                                                                                                                                                                                         F4A(11-04) PDF
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                                                                                        Request for Change                        • PRE-AUTHORIZED CHEQUE PAYMENTS (PAC)                                 F4A-02
                                                                                              Life and Critical                     AGREEMENT
                                                                                             Illness Insurance

4. PRE-AUTHORIZED CHEQUE PAYMENTS (PAC) AGREEMENT

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./Industrial Alliance Pacific 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 either as Personal or Business* depending on the choice I make here below.
• 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.
*Business PAC means a PAC for the payment of goods or services related to a business or commercial activity of the payor.

GENERAL INFORMATION
Name of Policyowner(s): _____________________________________________________________________________________________________________________
                        _____________________________________________________________________________________________________________________
Policy Number: ______________________________

1. Do you already pay by PAC?                                                                                                                                                            TO HEAD OFFICE
        No ➞ (Complete items 3 and 4 and sign.)                                      Yes ➞ (Complete items 2 and 4 and sign.)
2. Authorization number(1)                                         (1)
                                                                         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 specimen cheque; if a specimen cheque is attached, do not complete the banking information.
    Name of Financial Institution: ______________________________________________________________________________________________________________
    Name of Account holder(s): ________________________________________________________________________________________________________________
     ______________________________________________________________________________________________________________________________________
                       Branch #                                Institution #            Account #
                                                                                                                                                        1 This is the cheque number
                                                                                                                                                          (do not write this number).
                                                                                                                                                        2 This is the branch number (5 digits).
                                                                                                                                                        3 This is the financial institution number (3 digits).
                                                                                                                                                        4 This is the account number. The format may vary from
                                                                                                                                                          one financial institution to another.
               1                           2                        3                                4                                                    Indicate all numbers and only the numbers.

4. Withdrawal Arrangement: Variable                                         PAC category:           Personal    Business (If both boxes are left unchecked, the PAC category will be considered “Personal”.)
                   Y       Y       Y       Y       M       M       D       D
    Starting
    Day of withdrawal:                         Same as existing PAC                                                       Amount of PAC:           Minimum premium for contract
                                               Day: _______ (1 to 28)                                                                              Target premium (UL): $____________________________
Signature (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).)

         Y     Y       Y       Y       M       M       D       D
Date:                                                                               X
                                                                                    _______________________________________________________________
                                                                                                                 Account holders’ signature
         Y     Y       Y       Y       M       M       D       D
Date:                                                                               X
                                                                                    _______________________________________________________________
                                                                                                                   Policyowners’ signature

Contact Information:
Quebec:      Industrial Alliance Insurance and Financial Services Inc., Customer Service, 1080 Grande Allée West, PO Box 1907, Station Terminus, Quebec, Quebec G1K 7M3
             Telephone: 418 684-5000, Toll-free: 1 800 463-6236, Fax: 418 684-5208, Email: clientele@inalco.com
Toronto:       Industrial Alliance Insurance and Financial Services Inc., Customer Service, 522 University Avenue, Toronto, Ontario M5G 1Y7
               Telephone: 416 585-8862, Toll-free: 1 800 242-9751, Fax: 416 204-4777, Email: iat-clientservices@inalco.com
Vancouver: Industrial Alliance Pacific Insurance and Financial Services Inc., PFS – Life Administration, 2165 Broadway West, PO Box 5900, Vancouver, BC V6B 5H6
           Telephone: 604 737-9384, Fax: 604 739-0534, Email: intouch@iapacific.com
                                                                                                                                                                                                           F4A(11-04) PDF
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                                                               Request for Change                              • ADDITION OF COVERAGE AND/OR ADDITIONAL
                                                                      Life and Critical                          BENEFITS                                                         F4A-03
                                                                     Illness Insurance                         • ADDITION OF 10-15-20 OPTION
                                                                                                                 (UNIVERSAL LIFE POLICY)
MANDATORY INFORMATION
Agency                                                       Agency Code             Agent                                                           Agent code
                                                                                                                                                                                         SU




                                                              Principal insured’s last and first name                                                               Amount received
Policy no.

             -                                    -                                                                                                                  $
                                                                                                                                             Date (yyyy-mm-dd)                Initials
                                                                                                                         Reserved for H.O.
                 Please check

5.                ADDITION OF COVERAGE AND/OR ADDITIONAL BENEFITS


                 ➡ Attach a duly completed and signed F3A form for each insured for which the request to add coverage applies.
5.1 Coverage to be added:
Insured (last and first name)                                              Type of coverage                                 Face amount added               Annual premium added
______________________________________________________________________     __________________________________________       $__________________________     $__________________________
______________________________________________________________________     __________________________________________       $__________________________     $__________________________
______________________________________________________________________     __________________________________________       $__________________________     $__________________________
______________________________________________________________________     __________________________________________       $__________________________     $__________________________

                                                                                                                  TOTAL PREMIUM OF ADDITION:                $__________________________       1

5.2 Does the policy contain the CAD, CID, CADE, WP, WPDis or WPD benefits?                              Yes ➡ Attach a F3A form for the policyowner if the addition leads to an increase in
                                                                                                              the annual premium of $300 or more.

5.3 Is Critical Illness coverage being added?                                                           Yes ➡ Attach completed and signed F3A and Q4A forms for each insured in which
                                                                                                              coverage is being added.

5.4 Is Disability coverage being added?                                                                 Yes ➡ Attach completed and signed F3A and Q6A forms for each insured in which
                                                                                                              coverage is being added.

5.5 Is Home Protection coverage being added?                                                            Yes ➡ Attach completed and signed F3A and Q8A forms for each insured in which
                                                                                                              coverage is being added.

5.6 Is Life and Serenity coverage being added?                                                          Yes ➡ Attach completed and signed F3A and Q9A forms for each insured in which
                                                                                                              coverage is being added.

5.7 Is a cheque equivalent to one monthly premium attached to this request?                             Yes ➡ Complete and remit to the client form F4A-17A Interim Insurance
                                                                                                              Agreement in the Event of Death or Critical Illness.

5.8 For a universal life policy, I want to:           Change the target premium to (amount): $ ________________.
                                                      Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                                                      Maintain the current target premium.
                 Please check
6.                ADDITION OF 10-15-20 OPTION (UNIVERSAL LIFE POLICY)

Warning: If the current cost of insurance is YRT, we will automatically change it to level if the policy has been in force for more than three years. Caution: For certain types of
         joint coverages, the levelling of the cost of insurance is not allowed within the first ten years. Please refer to the policy.

6.1 I want to add:                Option 10 for the following insured(s): _______________________________________                      __________________________________________
                                  Option 15 for the following insured(s): _______________________________________                      __________________________________________
                                  Option 20 for the following insured(s): _______________________________________                      __________________________________________

6.2 I want to:            Change the target premium to (amount): $ ________________.
                          Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                          Maintain the current target premium.




                                                                                                                                                                                    F4A(11-04) PDF
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                                                                                                                                                                  F4A-03

DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                           SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


  X
 ____________________________________         X
                                             ____________________________________         X
                                                                                         ____________________________________          X
                                                                                                                                      ____________________________________
 Agent                                       Irrevocable Beneficiary/Assignee            Policyowner/Authorized person                Policyowner/Authorized person


                                              X
                                             ____________________________________
                                             Proposed insured




                                                                                                                                                                   F4A(11-04) PDF
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                                                                Request for Change                      • CANCELLATION/REDUCTION OF COVERAGE AND/OR                            F4A-04
                                                                        Life and Critical                 ADDITIONAL BENEFITS
                                                                       Illness Insurance

MANDATORY INFORMATION
Agency                                                        Agency Code            Agent                                                       Agent code
                                                                                                                                                                                      SU




                                                              Principal insured’s last and first name                                                            Amount received
Policy no.

             -                                    -                                                                                                               $
                                                                                                                                         Date (yyyy-mm-dd)                 Initials
                                                                                                                     Reserved for H.O.
                 Please check

7.                CANCELLATION/REDUCTION OF COVERAGE AND/OR ADDITIONAL BENEFITS

7.1 Is the entire policy being surrendered?                            Yes ➡ Use form F6A.
                                                                       No ➡ Continue at section 7.2.
7.2 Coverage to be cancelled/reduced:

      Insured (last and first name)                          Type of Coverage                                                                                 Cancelled Annual Premium

                                                                                                        Cancel the entire coverage
      ___________________________________________________    __________________________________         Reduce the face amount to $______________________ $______________________

                                                                                                        Cancel the entire coverage
      ___________________________________________________    __________________________________         Reduce the face amount to $______________________ $______________________

                                                                                                        Cancel the entire coverage
      ___________________________________________________    __________________________________         Reduce the face amount to $______________________ $______________________

                                                                                                        Cancel the entire coverage
      ___________________________________________________    __________________________________         Reduce the face amount to $______________________ $______________________

                                                                                                                                                     Total: $______________________        2

7.3 Indicate the TOTAL PREMIUM OF ADDITION indicated in section 5.1 of page F4A-03 if applicable.                                                             $______________________      1

7.4 Increase in net premium excluding the premium adjustment for existing CAD, CID, CADE, WP, WPDis or WPD benefits                          1   - 2     = $______________________

7.5 Is this a universal life policy?                                                         Yes ➡ Include a $25 cheque for transaction fees.
                                                                                             No ➡ No transaction fees.

7.6 The cancellation is conditional on the acceptance of the:                                New application no.: ______________________________
                                                                                             Addition of coverage on policy: ________________________________________

7.7 Is the cancelled coverage replaced by a new coverage?                                    Yes ➡ Attach a Notice of Replacement.

7.8 Is the type of beneficiary on the coverage to be cancelled irrevocable?                  Yes ➡ The irrevocable beneficiary(ies) must sign at the SIGNATURES section.

7.9 If the cancelled coverage contains surrender values,                                     Payment to the policyowner by cheque.
    how will they be paid?                                                                   Deposit on contract no. ______________________________________
     Warning: If there is a loan against the policy, it will be paid                         Deposit on application no. ________________________________
     off before the payment of a surrender value.
                                                                                             Direct deposit
                                                                                             ➡ The bank account holder must be the policyowner.
                                                                                                      Use the policy’s current bank account
                                                                                                      Use the bank account specified on the attached personalized cheque.

7.10 Is the contract assigned for collateral security?                                       Yes ➡ Obtain a release of assignment or the consent and seal of the financial institution.

7.11 Is it a Home Protection Plan policy?                                                    Yes ➡ Attach a completed and signed Q8A form.

7.12 For a universal life policy, I want to:          Change the target premium to (amount): $ ________________.
                                                      Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                                                      Maintain the current target premium.



                                                                                                                                                                                 F4A(11-04) PDF
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                                                                                                                                                                        F4A-04

DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                              SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by Industrial Alliance/
 Industrial Alliance Pacific.



 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


  X
 ____________________________________           X
                                               ____________________________________           X
                                                                                             ____________________________________           X
                                                                                                                                           ____________________________________
 Agent                                         Irrevocable Beneficiary/Assignee              Policyowner/Authorized person                 Policyowner/Authorized person




                                                                                                                                                                         F4A(11-04) PDF
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                                                              Request for Change                       • REINSTATEMENT/POLICY NOT PLACED                                       F4A-05
                                                                     Life and Critical
                                                                    Illness Insurance

MANDATORY INFORMATION
Agency                                                    Agency Code               Agent                                                      Agent code
                                                                                                                                                                                      SU




                                                             Principal insured’s last and first name                                                            Amount received
Policy no.

             -                                   -                                                                                                               $
                                                                                                                                      Date (yyyy-mm-dd)                    Initials
                                                                                                                  Reserved for H.O.
                 Please check

8.                REINSTATEMENT/POLICY NOT PLACED

Warning:     ➡ Acceptance of a cheque does not mean that the reinstatement has been accepted. The insurability declarations will have to be reviewed before
                   acceptance of the request is confirmed.
             ➡ In all cases, attach a cheque for premiums due.
             ➡ Interest applies in some situations.
Does the banking information for this policy need to be modified?                                        Yes ➡ Complete section 2 of the F4A-01.

8.1 REINSTATEMENT

Is this a universal life policy?                                                                         Yes ➡ Include $25 for transaction fees.

Is this a cancelled policy with a surrender value?                                                       Yes ➡ Include a cheque for the reimbursement of the surrender value paid
                                                                                                               to the policyowner.

Is this a cancelled contract with a loan (loan exceeded surrender value)?                                Yes ➡ Include a cheque for a total or partial loan repayment.
                                                                                                               Amount: $_______________________

How long has the policy been cancelled?                                                                  Less than 120 days ➡ Please complete section 8.3.
                                                                                                         More than 120 days ➡ Please continue at section 8.4.

8.2 POLICY NOT PLACED

➡ No transaction fees.
Do you wish to place the policy with a change of effective date?                                         Yes ➡ Enclose a cheque for the modal premium and attach the policy to
                                                                                                                 this request.
How long has the policy been terminated?                                                                 Less than 120 days ➡ Complete section 8.3.
                                                                                                         More than 120 days ➡ Submit a new application, since a reinstatement is
                                                                                                                               not allowed. This form is not required.



8.3 POLICY CANCELLED OR NOT PLACED FOR LESS THAN 120 DAYS

Is this a simplified issue policy such as Alternative, Perspective or Transition Simplified?             Yes ➡ Attach to this request the application for the product concerned,
                                                                                                               completed and signed for each insured.
 1   This statement concerns:                  each insured on the policy
                                               the following insured(s):_____________________________________________________
 2   In the last year, have any of the insureds indicated in 1 above:
     a) suffered from any illness, had health problems or consulted a physician?                         No       Yes
                                                                                                                            If the answer to any of these questions is “Yes”, submit a
                                                                                                                        ▲




     b) tested positive for an AIDS screening test or for Hepatitis B or C?                              No       Yes       completed and signed F3A form for each applicable insured.
     c) been disabled or absent from work for more than two weeks for health reasons?                    No       Yes

     If the policy contains a disability insurance coverage, also answer question d):
     d) In the last five years, have any of the insureds indicated in 1 suffered from nervous                               If the answer to this question is “Yes”, submit completed and
                                                                                                                        ▲




         disorders (fatigue, anxiety, depression, anguish, overwork, burnout or other)                   No       Yes       signed F3A and Q6A forms for each applicable insured.
         or musculoskeletal disorders (herniated disk, vertebra related disorders, disorders
         of the neck, back, shoulders, elbows, knees or other joints), osteoarthrosis
         or arthritis?


                                                                                                                            If the answer to this question is “Yes”, submit a completed and
     Does the policy contain Critical Illness insurance coverage?                                        No       Yes
                                                                                                                        ▲




                                                                                                                            signed Q4A form for each applicable insured.




                                                                                                                                                                                 F4A(11-04) PDF
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                                                                                                                                                                  F4A-05

8.4 POLICY CANCELLED FOR 120 DAYS OR MORE

➡ Submit duly completed and signed F3A form for each applicable insured.
Is this a simplified issue policy such as Alternative, Perspective or
Transition Simplified?                                                                        Yes ➡ Attach the application related to the product concerned.

Does the policy contain Critical Illness coverage?                                            Yes ➡ Attach completed and signed F3A and Q4A forms for each insured
                                                                                                    under this coverage.

Does the policy contain disability coverage?                                                  Yes ➡ Attach forms F3A and Q6A completed and signed for each insured
                                                                                                    covered under this coverage.

Does the policy contain Life and Serenity coverage?                                           Yes ➡ Attach forms F3A and Q9A completed and signed for each insured
                                                                                                    covered under this coverage.

DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                           SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


   X
  ____________________________________          X
                                               ____________________________________       X
                                                                                         ____________________________________          X
                                                                                                                                      ____________________________________
  Agent                                        Irrevocable Beneficiary/Assignee          Policyowner/Authorized person                Policyowner/Authorized person




                                                                                                                                                                   F4A(11-04) PDF
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                                                                Request for Change                       • TOBACCO STATUS (CHANGE TO NON-SMOKER)                           F4A-06
                                                                       Life and Critical
                                                                      Illness Insurance

MANDATORY INFORMATION
Agency                                                        Agency Code             Agent                                                      Agent code
                                                                                                                                                                                  SU




                                                               Principal insured’s last and first name                                                        Amount received
Policy no.

              -                                    -                                                                                                          $
                                                                                                                                         Date (yyyy-mm-dd)             Initials
                                                                                                                     Reserved for H.O.
                  Please check
9.                 TOBACCO STATUS (CHANGE TO NON-SMOKER)


                  ➡ Attach a duly completed and signed F3A form for each applicable insured.
9.1 Change the tobacco status to non-smoker for the following insured(s): _____________________________________________________________________________

                                                                                       _____________________________________________________________________________

9.2 Indicate for which type of policy or insured the change is requested for:

             For a policy that was issued at a smoker rate due to age (child under age 15):
             ➡ Changes for children under age 15 when the original policy was issued will all be effectuated using the attained age.
             ➡ No transaction fees.
     OR

             For an insured aged 15 or more at issue who stopped using tobacco: Choose the applicable transaction fee and attach a cheque to the request
                 If 12 months or less since the coverage was issued: No fees (the change will be effectuated according to the insured’s age at issue and the original rate).
                 If between 1 and 5 years since the coverage was issued: $50 fee (the change will be effectuated according to the insured’s age at issue and the original rate).
                 If more than 5 years since the coverage was issued: No fees (the change will be effectuated according to the insured’s attained age and the original rate).
                 ➡ Attention: Please make sure that the non-smoker premium at the attained age is to the client’s advantage compared to the smoker premium currently in
                 effect.
9.3 Is it Joint Last to Die coverage?                             Yes ➡ Attach a F3A form for each joint insured under this coverage.

9.4 Is it Critical Illness coverage?                              Yes ➡ Attach completed and signed F3A and Q4A forms for each insured involved in this change.

9.5 Is it Disability coverage?                                    Yes ➡ Attach completed and signed F3A and Q6A forms for each insured involved in this change.

9.6 Is it Life and Serenity coverage?                             Yes ➡ Attach completed and signed F3A and Q9A forms for each insured involved in this change.

9.7 For a Universal Life policy, I want to:            Change the target premium to (amount): $ ________________.
                                                       Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                                                       Maintain the current target premium.




DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                    SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


 X
 ____________________________________              X
                                                  ____________________________________                X
                                                                                                     ____________________________________        X
                                                                                                                                                ____________________________________
 Agent                                            Irrevocable Beneficiary/Assignee                   Policyowner/Authorized person              Policyowner/Authorized person


                                                                                                                                                                             F4A(11-04) PDF
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                                                             Request for Change                         • RISK CLASS (CHANGE TO PREFERRED, ELITE)                             F4A-07
                                                                    Life and Critical
                                                                   Illness Insurance

MANDATORY INFORMATION
Agency                                                     Agency Code             Agent                                                           Agent code
                                                                                                                                                                                     SU




                                                            Principal insured’s last and first name                                                              Amount received
Policy no.

             -                                  -                                                                                                                $
                                                                                                                                          Date (yyyy-mm-dd)               Initials
                                                                                                                      Reserved for H.O.
                 Please check
10.               RISK CLASS (CHANGE TO PREFERRED, ELITE)


            ➡ Attach a duly completed and signed F3A form for each applicable insured.
10.1 Has the coverage been issued for more than two years?                       Yes ➡ Attach a $50 cheque for transaction fees (the change will be effectuated according
                                                                                                      to the age at issue and the original rate)

                                                                                           No ➡ The change is not allowed.

10.2 Change the risk class:
      ➡ The preferred selection criteria in effect when the request for change is made will apply.
      Insured (Last and first name)
      ____________________________________________________________________________ for the following class:                                     Preferred        Elite

      ____________________________________________________________________________ for the following class:                                     Preferred        Elite

      ____________________________________________________________________________ for the following class:                                     Preferred        Elite

10.3 Is it Joint Last to Die coverage?                         Yes ➡ Attach a F3A form for each joint insured under this coverage.

10.4 Is it Critical Illness coverage?                          Yes ➡ Attach completed and signed F3A and Q4A forms for each insured involved in this change.

10.5 Is it Disability coverage?                                Yes ➡ Attach completed and signed F3A and Q6A forms for each insured involved in this change.

10.6 Is it Life and Serenity coverage?                         Yes ➡ Attach completed and signed F3A and Q9A forms for each insured involved in this change.

10.7 For a Universal Life policy, I want to:        Change the target premium to (amount): $ ________________.
                                                    Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                                                    Maintain the current target premium.




DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                 SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


  X
  ____________________________________          X
                                               ____________________________________                X
                                                                                                  ____________________________________              X
                                                                                                                                                   ____________________________________
  Agent                                        Irrevocable Beneficiary/Assignee                   Policyowner/Authorized person                    Policyowner/Authorized person


                                                                                                                                                                                F4A(11-04) PDF
                                                                                 Validate and Print

                                                              Request for Change                       • EXTRA PREMIUM/EXCLUSION (REVISION)                              F4A-08
                                                                     Life and Critical
                                                                                                       • YRT TO LEVEL COST OF INSURANCE
                                                                    Illness Insurance
                                                                                                         (UNIVERSAL LIFE POLICY)

MANDATORY INFORMATION
Agency                                                      Agency Code             Agent                                                      Agent code
                                                                                                                                                                                SU




                                                             Principal insured’s last and first name                                                        Amount received
Policy no.

             -                                   -                                                                                                            $
                                                                                                                                       Date (yyyy-mm-dd)             Initials
                                                                                                                   Reserved for H.O.
                 Please check

11.               EXTRA PREMIUM/EXCLUSION (REVISION)

                 ➡ Attach a duly completed and signed F3A form for each applicable insured.
11.1 Revise the extra premium for the following insured(s): ______________________________________________                       __________________________________________

11.2 Is it Joint Last to Die coverage?                          Yes ➡ Attach a F3A form for each joint insured under this coverage.

11.3 Is it Critical Illness coverage?                           Yes ➡ Attach completed and signed F3A and Q4A forms for each insured involved in this change.

11.4 Is it Disability coverage?                                 Yes ➡ Attach completed and signed F3A and Q6A forms for each insured involved in this change.

11.5 Is it Life and Serenity coverage?                          Yes ➡ Attach completed and signed F3A and Q9A forms for each insured involved in this change.

11.6 Is it a universal life policy?                             Yes ➡ Attach a $25 cheque for transaction fees.
                                                                No ➡ No transaction fees.

11.7 For a universal life policy, I want to:         Change the target premium to (amount): $ ________________.
                                                     Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                                                     Maintain the current target premium.
                 Please check

12.               YRT TO LEVEL COST OF INSURANCE (UNIVERSAL LIFE POLICY)


            ➡ Verify if the current target premium is sufficient to maintain the policy in force, if not, modify it at section 12.3.
            ➡ Obtain the irrevocable beneficiary’s signature if the rate change leads to a reduced face amount.
            ➡ Obtain a release of assignment or consent and seal of the financial institution if the policy is assigned for collateral security.
            ➡ Attach a $25 cheque for transaction fees.
            ➡ For certain types of joint coverages, the levelling of insurance costs is not allowed within the first ten years. Please refer to the policy.
12.1 Has the coverage to be levelled been in force for more than three years?          No ➡ The change is not allowed.

12.2 Change the cost of insurance to level and guaranteed for life for the following insureds: ______________________________________________________________
         ➡ The change will be effectuated according to the insured’s attained age.                       ______________________________________________________________


12.3 I want to:           Change the target premium to (amount): $ ________________.
                          Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                          Maintain the current target premium.

DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                  SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


  X
  ____________________________________           X
                                                ____________________________________                X
                                                                                                   ____________________________________        X
                                                                                                                                              ____________________________________
  Agent                                         Irrevocable Beneficiary/Assignee                   Policyowner/Authorized person              Policyowner/Authorized person


                                                                                                                                                                           F4A(11-04) PDF
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                                                              Request for Change                      • DEATH BENEFIT (UNIVERSAL LIFE POLICY)                               F4A-09
                                                                    Life and Critical
                                                                                                      • REDUCED PAID-UP POLICY
                                                                   Illness Insurance

MANDATORY INFORMATION
Agency                                                     Agency Code             Agent                                                       Agent Code
                                                                                                                                                                                   SU




                                                            Principal insured’s last and first name                                                            Amount received
Policy no.

              -                                   -                                                                                                            $
                                                                                                                                       Date (yyyy-mm-dd)                Initials
                                                                                                                   Reserved for H.O.
                  Please check

13.                DEATH BENEFIT (UNIVERSAL LIFE POLICY)

Warning: The death benefit can only be changed for the principal insured.

➡ Obtain a release of assignment or consent and seal of the financial institution if the policy is assigned for collateral security.
➡ Attach a $25 cheque for transaction fees.
13.1 Select the new type of death benefit:            Face amount only
                                                      Face amount + fund     ➡     Is the type of death benefit currently “Face amount only”?
                                                                                         Yes ➡         I want to keep the current face amount.
                                                                                                       I want to maintain my face amount to the original amount.
                                                                                                       ➡ Attach a completed and signed F3A form.
                  Please check

14.                REDUCED PAID-UP POLICY


➡ Obtain the irrevocable beneficiary’s signature.
➡ Obtain a release of assignment or consent and seal of the financial institution if the policy is assigned for collateral security.
14.1 Select the portion of the policy you want to pay up and for which insureds:

             1. Pay up 25% of the face amount (Caution: applicable only to Modular A4 on the insured’s 65th birthday)
      OR
             2. The entire policy
               ➡ The policy’s total values will be used.
      OR
             3. For the following insured(s): _____________________________________________                     ➡ Select one of the following two options:
                                              _____________________________________________                         1. The coverage for the other insureds remains in force.
            ➡ Only the values of the selected insureds will be used.                                                2. The coverage for the other insureds must be cancelled.

14.2 Is there a policy loan on the contract?       Yes ➡ I want to:              Keep the policy loan if surrender values remain once the policy is paid-up.
                                                                                 Keep the policy loan by reducing the paid-up amount.


DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                 SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


 X
 ____________________________________             X
                                                 ____________________________________              X
                                                                                                  ____________________________________         X
                                                                                                                                              ____________________________________
 Agent                                           Irrevocable Beneficiary/Assignee                 Policyowner/Authorized person               Policyowner/Authorized person


                                                                                                                                                                              F4A(11-04) PDF
                                                                                    Validate and Print

                                                                 Request for Change                       • CHANGE IN TYPE OF PLAN                                                 F4A-10
                                                                        Life and Critical
                                                                       Illness Insurance

MANDATORY INFORMATION
Agency                                                         Agency Code             Agent                                                          Agent code
                                                                                                                                                                                          SU




                                                                Principal insured’s last and first name                                                              Amount received
Policy no.

             -                                       -                                                                                                                $
                                                                                                                                              Date (yyyy-mm-dd)                Initials
                                                                                                                          Reserved for H.O.
                 Please check

15.               CHANGE IN TYPE OF PLAN


                 ➡ Allows for a change retroactive to issue within 13 months following the issue date of a policy.
                 ➡ If there is reduction in coverage, the cancellation/reduction is first applied as of the current date and the change of plan is effective at the issue date.
                 ➡ For a universal life policy, the bonus option can only be changed within the first three months of the issue of the policy.
                 ➡ Attach the policy to this request.
                 ➡ Obtain the irrevocable beneficiary’s signature if the change involves a reduction in the face amount.
                 ➡ Obtain a release of assignment or the consent and seal of the financial institution if the policy is assigned for collateral security.
15.1 Protection to change:
      Insured (last and first name)                                                Current plan                              New plan                               New face amount
      ______________________________________________________________________       ____________________________________      ____________________________________   $________________________
      ______________________________________________________________________       ____________________________________      ____________________________________   $________________________
      ______________________________________________________________________       ____________________________________      ____________________________________   $________________________
      ______________________________________________________________________       ____________________________________      ____________________________________   $________________________

15.2 Has the policy been issued for more than 3 months?                                        Yes ➡ Attach a $50 cheque for transaction fees.
                                                                                               No ➡ No transaction fees

15.3 Will the new premium be higher than the old premium?                                      Yes ➡ Attach a cheque for the difference in premium since issue.
                                                                                                     Amount: $________________

15.4 Is there an increase in the face amount of the life insurance?                            Yes ➡ Attach a completed and signed F3A form for each insured involved in this change.

15.5 Is there an increase in the face amount of the Critical Illness coverage?                 Yes ➡ Attach completed and signed F3A and Q4A forms for each insured involved in this
                                                                                                     change.

15.6 Is there an increase in the disability coverage?                                          Yes ➡ Attach completed and signed F3A and Q6A forms for each insured involved in this
                                                                                                     change.

15.7 Is there an increase in the Life and Serenity coverage?                                   Yes ➡ Attach completed and signed F3A and Q9A forms for each insured involved in this
                                                                                                     change.

15.8 Is the type of product changing from a traditional policy                                 Yes ➡ Attach a completed and signed F1A form, including the Confirmation of Identity
     to a universal life policy?                                                                     section, but excluding the declarations of insurability if there is no increase in
                                                                                                     coverage.
                                                                                                  ➡ Attach an illustration signed by the policyowner.
DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                     SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


 X
 ____________________________________               X
                                                   ____________________________________                X
                                                                                                      ____________________________________            X
                                                                                                                                                     ____________________________________
 Agent                                             Irrevocable Beneficiary/Assignee                   Policyowner/Authorized person                  Policyowner/Authorized person


                                                                                                                                                                                     F4A(11-04) PDF
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                                                                                                   • DUPLICATE POLICY
                                                         Request for Change                        • DATE OF BIRTH (CORRECTION)                                      F4A-11
                                                               Life and Critical
                                                              Illness Insurance

MANDATORY INFORMATION
Agency                                                  Agency Code             Agent                                                      Agent code
                                                                                                                                                                            SU




                                                         Principal insured’s last and first name                                                        Amount received
Policy no.

             -                                -                                                                                                         $
                                                                                                                                   Date (yyyy-mm-dd)             Initials
                 Please check                                                                                  Reserved for H.O.

16.               DUPLICATE POLICY

16.1 DUPLICATE POLICY
     ➡ Enclose a $30 cheque for transaction fees.
     ➡ The policyowner’s signature is mandatory.
                 Please check

17.               DATE OF BIRTH (CORRECTION)

17.1 CORRECT THE DATE OF BIRTH for the following insured: ______________________________________________________
     ➡ Attach proof of date of birth.
     ➡ Warning: In some situations, premiums in arrears and interest are applicable.




DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                              SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


 X
 ____________________________________         X
                                             ____________________________________               X
                                                                                               ____________________________________        X
                                                                                                                                          ____________________________________
 Agent                                       Irrevocable Beneficiary/Assignee                  Policyowner/Authorized person              Policyowner/Authorized person


                                                                                                                                                                       F4A(11-04) PDF
                                                                                   Validate and Print

                                                               Request for Change                        • EXERCISE THE GUARANTEED INSURABILITY (GI)                             F4A-12
                                                                     Life and Critical                     BENEFIT
                                                                    Illness Insurance

MANDATORY INFORMATION
Agency                                                         Agency Code            Agent                                                        Agent code
                                                                                                                                                                                        SU




                                                               Principal insured’s last and first name                                                             Amount received
Policy no.

             -                                    -                                                                                                                $
                                                                                                                                           Date (yyyy-mm-dd)                 Initials
                                                                                                                      Reserved for H.O.
                 Please check

18.               EXERCISE GUARANTEED INSURABILITY (GI)

Warning: If you also want to change the policyowner for this contract, enclose forms F30A and F5A with this request.
         If this exercise of Guaranteed Insurability leads to a transfer of ownership rights, the policyowner(s) and the current irrevocable beneficiary(ies) give up all their
         rights in favour of the new policyowner(s).
         If this exercise of Guaranteed Insurability leads to a transfer of ownership rights and the policy is assigned for collateral security, please obtain a release of
         assignment or the consent and seal of the financial institution.
         Complete a Pre-Authorized Cheque Payments (PAC) Agreement on the F4A-02 for each new payor resulting from this transaction.
18.1 Information required:
     1. Insured (last and first name)                                               Face amount                          New plan

         ___________________________________________________________________        $______________________________      ___________________________________________________________________

         Beneficiary                                                    Date of birth (yyyy-mm-dd)              %                          Relationship to insured
                                                                    M                                                        Revocable
         ___________________________________________________        F                                       __________       Irrevocable    __________________________________________________



      2. Insured (last and first name)                                              Face amount                          New plan

         ___________________________________________________________________        $______________________________      ___________________________________________________________________

         Beneficiary                                                    Date of birth (yyyy-mm-dd)              %                          Relationship to insured
                                                                    M                                                        Revocable
         ___________________________________________________        F                                       __________       Irrevocable    __________________________________________________



      3. Insured (last and first name)                                              Face amount                          New plan

         ___________________________________________________________________        $______________________________      ___________________________________________________________________

         Beneficiary                                                    Date of birth (yyyy-mm-dd)              %                          Relationship to insured
                                                                    M                                                        Revocable
         ___________________________________________________        F                                       __________       Irrevocable    __________________________________________________


18.2 Is the insured aged 15 or over?            Yes ➡ The insured must sign this request at the SIGNATURES section.

18.3 Do you want to add coverage or additional benefits other than the coverage
     granted under the exercise of the GI?                                                                Yes ➡ Please complete section 5 of the F4A-03.

18.4 Is there a change in the risk class or tobacco status for the new coverage?                          Yes ➡ Attach a completed and signed F3A form for each insured involved in
                                                                                                                this change.

18.5 Does the policy have the CAD, CID, CADE, WP, WPDis and WPD benefits?                                 Yes ➡ Attach form F3A for the policyowner.

18.6 For a universal life policy, I want to:          Change the target premium to (amount): $ ________________.
                                                      Set the target premium at the higher between the minimum premium and the monthly cost + taxes.
                                                      Maintain the current target premium.




                                                                                                                                                                                   F4A(11-04) PDF
                                                                                  Validate and Print


                                                                                                                                                                               F4A-12

18.7 Select ONE of the following three options:

           1. The insurance purchased will be added to the current policy.
     OR
           2. The insurance purchased will be added to a new policy(ies).
                                                                                             Ownership rights of the new policy(ies) resulting from exercising the Guaranteed Insurability
          ➡ Enclose the F1A form (completed and signed by the policyowner                        1. I will be owner of the new policy.
              of the new policy) and make a choice in the right section.




                                                                                         ▲
                                                                                                 2. I assign each applicable insured their own policy.
          ➡ For a universal life policy, fill out the Confirmation of Identity section           3. I assign ownership of the new policy to __________________________ .
              and attach an illustration signed by the policyowner.
     OR
           3. The insurance purchased will be added and assigned to the owner of policy no.___________________________
          ➡ The policyowner of the above-mentioned policy must agree to the addition to his/her policy by signing hereinbelow.
          ➡ If the policy includes the CAD, CID, CADE, WP, WPDis or WPD, attach the F3A form for the policyowner.
                 I agree to the addition of the insurance to my insurance policy. The addition will take effect
                 when the transaction is accepted by Industrial Alliance/Industrial Alliance Pacific.
                                                                                                                                                         IMPORTANT
                                                                                                                                              Please also fill out the SIGNATURES
                                                                                                                                              section herein-below to complete
                 ___________________________________                   ___________________________________                                    this transaction.
                 Policyowner                                           Policyowner


DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                   SIGNATURES
  We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
  the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
  the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


  Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


   X
  ____________________________________             X
                                                  ____________________________________             X
                                                                                                  ____________________________________               X
                                                                                                                                                    ____________________________________
  Agent                                           Irrevocable Beneficiary/Assignee                Policyowner/Authorized person                     Policyowner/Authorized person


                                                   X
                                                  ____________________________________
                                                  Proposed insured




                                                                                                                                                                                 F4A(11-04) PDF
                                                                                    Validate and Print

                                                                Request for Change                        • CONVERSION                                                           F4A-13
                                                                      Life and Critical
                                                                     Illness Insurance

MANDATORY INFORMATION
Agency                                                          Agency Code            Agent                                                       Agent code
                                                                                                                                                                                        SU




                                                                Principal insured’s last and first name                                                            Amount received
Policy no.

               -                                    -                                                                                                               $
                                                                                                                                           Date (yyyy-mm-dd)                 Initials
                   Please check                                                                                        Reserved for H.O.

19.                 CONVERSION

Warning: If you also want to change the policyowner for this contract, attach forms F30A and F5A to this request.
         If this conversion leads to a transfer of ownership rights, the policyowner(s) and the current irrevocable beneficiary(ies) give up all their rights in favour of the new
         policyowner(s).
         If this conversion leads to a transfer of ownership rights and the policy is assigned for collateral security, please obtain a release of assignment or the consent and
         seal from the financial institution.
         Complete a Pre-Authorized Cheque Payments (PAC) Agreement on the F4A-02 for each new payor resulting from this transaction.
19.1 Select ONE of the following three options:

             1. Total conversion: the total amount of coverage is converted into permanent insurance.
      OR
             2. Partial conversion: the balance of the insurance remains in force.
      OR
             3. Partial conversion: the balance of the insurance is cancelled.        ➡ Attach a Replacement Notice.
19.2 Information required
     1. Insured (last and first name)                          Converted plan                             New Face amount                          New type of plan

         ________________________________________________    _______________________________________      $____________________________________    ___________________________________________

         Beneficiary                                                     Date of birth (yyyy-mm-dd)              %                         Relationship to insured
                                                                     M                                                       Revocable
         ___________________________________________________         F                                       __________      Irrevocable    __________________________________________________



      2. Insured (last and first name)                       Converted plan                               New Face amount                          New type of plan

         ________________________________________________    _______________________________________      $____________________________________    ___________________________________________

         Beneficiary                                                     Date of birth (yyyy-mm-dd)              %                         Relationship to insured
                                                                     M                                                       Revocable
         ___________________________________________________         F                                       __________      Irrevocable    __________________________________________________



      3. Insured (last and first name)                       Converted plan                               New Face amount                          New type of plan

         ________________________________________________    _______________________________________      $____________________________________    ___________________________________________

         Beneficiary                                                     Date of birth (yyyy-mm-dd)              %                         Relationship to insured
                                                                     M                                                       Revocable
         ___________________________________________________         F                                       __________      Irrevocable    __________________________________________________

19.3 Additional benefits to be maintained in the new permanent insurance coverage following the conversion:
     ➡ Attach a duly completed and signed F3A form for additional benefits to be added.
     ➡ No change will be made to the additional benefits of the non-converted coverages.
     ➡ Only changes made to the converted portion of the insurance will apply according to the instructions given below.
     ➡ Additional benefits may not be transferrable to the new coverage following the conversion.
      Choose ONE of the following three options:

                    I want to keep the current additional benefits on the new converted coverage.
              OR
                    I want to keep only the following additional benefits on the new converted coverage:
                                                            CAD               WPDis             AD             GI                   Child Module
                                                            CADE              WPD               AD&D           Fracture
              OR
                    I do not want to keep the additional benefits in the new converted coverage.
                                                                                                                                                                                         F4A(11-04)
                                                                                  Validate and Print

                                                                                                                                                                               F4A-13

19.4 Select ONE of the following three options:

           1. The converted insurance will be added to the current policy.
     OR
           2. The converted insurance will be issued on a new policy(ies).
                                                                                             Ownership rights of the new policy(ies) resulting from exercising the Guaranteed Insurability
           ➡ Attach form F1A (completed and signed by policyowner of
               the new policy) and make a selection in the right section.                        1. I will be owner of the new policy.




                                                                                         ▲
                                                                                                 2. I assign each applicable insured their own policy.
          ➡ For a universal life policy, fill out the Confirmation of Identity section
              and attach an illustration signed by the policyowner.                              3. I assign ownership of the new policy to __________________________ .
     OR
           3. The converted insurance will be added and assigned to the owner of policy no.___________________________
           ➡ The policyowner of the above-mentioned policy must agree to the addition to his/her policy by signing hereinbelow.
           ➡ If the policy includes the CAD, CID, CADE, WP, WPDis or WPD, attach the F3A form for the policyowner.
                 I agree to the addition of the converted insurance to my insurance policy. The addition will
                 take effect when the transaction is accepted by Industrial Alliance/Industrial Alliance Pacific.
                                                                                                                                                         IMPORTANT
                                                                                                                                              Please also fill out the SIGNATURES
                                                                                                                                              section herein-below to complete
                 ___________________________________                   ___________________________________                                    this transaction.
                 Policyowner                                           Policyowner


19.5 Do you want to add coverage or additional benefits other than the coverage granted under                            Yes ➡ Please complete section 5 of the F4A-03.
     the conversion clause?
19.6 Is there a change in the risk class or tobacco status for the converted coverage?                                   Yes ➡ Please attach the F3A form completed and signed for
                                                                                                                               each insured involved in this change.

19.7 Is Home Protection Plan coverage being converted?                                                                   Yes ➡ Attach a Q8A form completed and signed by the
                                                                                                                               policyowner.

19.8 Is the insured aged 15 or over                                                                                      Yes ➡ The insured must sign this request at the SIGNATURES
                                                                                                                               section herein-below.

DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                   SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


  X
 ____________________________________              X
                                                  ____________________________________             X
                                                                                                  ____________________________________               X
                                                                                                                                                    ____________________________________
 Agent                                            Irrevocable Beneficiary/Assignee                Policyowner/Authorized person                     Policyowner/Authorized person


                                                   X
                                                  ____________________________________
                                                  Proposed insured




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                                                             Request for Change                          • DISSOCIATION                                                         F4A-14
                                                                   Life and Critical
                                                                  Illness Insurance

MANDATORY INFORMATION
Agency                                                      Agency Code             Agent                                                          Agent code
                                                                                                                                                                                       SU




                                                             Principal insured’s last and first name                                                              Amount received
Policy no.

             -                                    -                                                                                                                $
                                                                                                                                           Date (yyyy-mm-dd)                Initials
                                                                                                                       Reserved for H.O.
                 Please check

20.               DISSOCIATION

Warning:     If you also want to change the policyowner for this contract, attach forms F30A and F5A to this request.
             If this dissociation leads to a transfer of ownership rights, the policyowner(s) and the current irrevocable beneficiary(ies) give up all their rights in favour of the new
             policyowner(s).
             If this dissociation leads to a transfer of ownership rights and the policy is assigned for collateral security, please obtain a release of assignment or the consent and
             seal from the financial institution.
             Complete a Pre-Authorized Cheque Payments (PAC) Agreement on the F4A-02 for each new payor resulting from this transaction.
20.1 Attach a $50 transaction fee, except in the following two cases:          ➡ The insured was age 18 or under when the policy was issued.
                                                                               ➡ The policy was issued less than three months ago.
20.2 Provide the following details on the following additional insureds to be dissociated:
      Insured (last and first name)                                               Plan to dissociate

      ______________________________________________________________________      ___________________________________________________________________________

      ______________________________________________________________________      ___________________________________________________________________________

      ______________________________________________________________________      ___________________________________________________________________________

      ______________________________________________________________________      ___________________________________________________________________________



FOR A UNIVERSAL LIFE POLICY:

20.3 Will the dissociated insurance be assigned to a new policyowner?                       Yes ➡ Complete the Confirmation of Identity section of form F1A, which contains
                                                                                                  information on the policyowner [mandatory under the Proceeds of Crime (Money
                                                                                                  Laundering) and Terrorist Financing Act].
20.4 If a surrender charge is applicable and a balance remains after the                    Yes ➡ Indicate the amount OR percentage to share for each insured:
     mandatory splitting of the accumulation fund, do you want to share                           Warning: the total amount of % must equal 100%.
     the balance of the fund between the current policy and the policies
     to be dissociated?                                                                                Insured (last and first name)                                    $ OR           %

                                                                                                       ____________________________________________________________ _________________________

                                                                                                       ____________________________________________________________ _________________________

                                                                                                       ____________________________________________________________ _________________________

                                                                                                       ____________________________________________________________ _________________________




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                                                                                                                                                                             F4A-14

20.4 Select ONE of the following three options:

          1. The dissociated insured(s) will be transferred to a single new policy
          ➡ Attach forms F1A and F3A (if more than one insured) completed and signed              Ownership rights of the new policy(ies) resulting from the dissociation:
              by the owner of the new policy excluding the insurability declarations and
              make a selection in the right section.                                                  1. I remain the owner of this or these new policy(ies).




                                                                                             ▲
     OR                                                                                               2. I assign each concerned insured ownership of their own policy.
          2.A new policy will be issued for each dissociated insured                                  3. I assign ownership of the new policy(ies) to ______________________________.
          ➡ Attach form F1A (completed and signed by owner of the new policy(ies)) and
              make a selection in the right section.
     OR
          3. The dissociated insurance will be transferred and assigned to the owner of policy no.___________________________
          ➡ The owner of the above-mentioned policy must agree to the addition to his/her policy by signing hereinbelow.
          ➡ If the policy contains the CAD, CID, CADE, WP, WPDis and WPD benefits, attach form F3A for the policyowner.
                I agree to the addition of the dissociated insurance to my insurance policy. The addition will
                take effect when the transaction is accepted by Industrial Alliance/Industrial Alliance Pacific.
                                                                                                                                                   IMPORTANT
                                                                                                                                     Please also fill out the SIGNATURES
                                                                                                                                     section herein-below to complete
                ___________________________________                ___________________________________                               this transaction.
                Policyowner                                        Policyowner


DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                            SIGNATURES
  We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
  the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
  the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


  Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


   X
  ____________________________________             X
                                                  ____________________________________      X
                                                                                           ____________________________________              X
                                                                                                                                            ____________________________________
  Agent                                           Irrevocable Beneficiary/Assignee         Policyowner/Authorized person                    Policyowner/Authorized person


                                                   X
                                                  ____________________________________
                                                  Proposed insured




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                                                               Request for Change                        • DISSOLUTION OF A JOINT 1ST TO DIE COVERAGE                         F4A-15
                                                                     Life and Critical
                                                                                                         • WITHDRAWAL OF AN INSURED FROM A JOINT 1ST
                                                                    Illness Insurance
                                                                                                           TO DIE COVERAGE

MANDATORY INFORMATION
Agency                                                         Agency Code            Agent                                                        Agent code
                                                                                                                                                                                     SU




                                                               Principal insured’s last and first name                                                           Amount received
Policy no.

             -                                      -                                                                                                            $
                                                                                                                                           Date (yyyy-mm-dd)              Initials
                                                                                                                       Reserved for H.O.
                 Please check

21.               DISSOLUTION OF A JOINT 1ST TO DIE COVERAGE


                 ➡ Following this dissolution transaction, the joint coverage will have been dissolved and only individual coverage will remain on the policy.
                 Warning: If you want to withdraw an insured from a joint coverage covering three insureds or more, please complete section 22 of the F4A-15.

21.1 Attach a $50 transaction fee, except in the following two cases:          ➡ The insured was age 18 or under when the policy was issued.
                                                                               ➡ The policy has been issued for less than three months.
21.2 Please indicate the insured(s) who want an individual coverage along with the face amount for each insured:
      Insured (last and first name)                                                   Face amount

      ______________________________________________________________________          $___________________________________

      ______________________________________________________________________          $___________________________________

      ______________________________________________________________________          $___________________________________

      ______________________________________________________________________          $___________________________________

21.3 Do you also want the insured(s) to be dissociated from this policy?                  Yes ➡ Please complete a dissociation request in section 20 of page F4A-14.
                 Please check

22.               WITHDRAWAL OF AN INSURED FROM A JOINT 1ST TO DIE COVERAGE


                 ➡ Following the withdrawal of one or more insureds, the other insureds will remain on the joint coverage.  At least two insureds must remain insured under the
                     joint coverage, otherwise you must complete a dissolution request at section 21 of the F4A-15. Each insured which has been withdrawn can either obtain
                     individual coverage or cancel the coverage.
22.1 Please indicate the joint insured(s) that want to be withdrawn from the joint coverage:

      Insured (last and first name)                                             Face amount
                                                                                                                              I want to keep the coverage on an individual basis.
      _________________________________________________________________         $___________________________________          I want to cancel the coverage.
                                                                                                                          ➡ For a universal life policy, attach a $25 transaction fee.
                                                                                                                              I want to keep the coverage on an individual basis.
      _________________________________________________________________         $___________________________________          I want to cancel the coverage.
                                                                                                                          ➡ For a universal life policy, attach a $25 transaction fee.
                                                                                                                              I want to keep the coverage on an individual basis.
      _________________________________________________________________         $___________________________________          I want to cancel the coverage.
                                                                                                                          ➡ For a universal life policy, attach a $25 transaction fee.
22.2 Do you also want the insured(s) to be dissociated from this policy?                  Yes ➡ Please complete a dissociation request in section 20 of the F4A-14.




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                                                                                                                                                                  F4A-15

DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                           SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


  X
 ____________________________________         X
                                             ____________________________________         X
                                                                                         ____________________________________          X
                                                                                                                                      ____________________________________
 Agent                                       Irrevocable Beneficiary/Assignee            Policyowner/Authorized person                Policyowner/Authorized person




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                                                            Request for Change                         • ASSOCIATION                                                         F4A-16
                                                                   Life and Critical
                                                                  Illness Insurance

MANDATORY INFORMATION
Agency                                                      Agency Code             Agent                                                      Agent code
                                                                                                                                                                                    SU




                                                             Principal insured’s last and first name                                                            Amount received
Policy no.

             -                                    -                                                                                                             $
                                                                                                                                       Date (yyyy-mm-dd)                 Initials
                                                                                                                   Reserved for H.O.
                 Please check

23.               ASSOCIATION

Warning:      If you also want to change the policyowner for this contract, enclose forms F30A and F5A to this request.
             If this association leads to a transfer of ownership rights, the policyowner(s) and the current irrevocable beneficiarie(s) give up all their rights in favour of the new
             policyowner(s).
             If this association leads to a transfer of ownership rights and the policy is assigned for collateral security, please obtain a release of assignment or the consent and
             seal from the financial institution.

➡ Note that a policy cannot include more than 9 insureds.
23.1 Attach a $50 transaction fee, except in the following two cases:      ➡ The insured was age 18 or under when the policy was issued.
                                                                           ➡ The policy has been issued for less than three months.
23.2 Important details on the policies to be associated:
     ➡ Traditional insurance products must be part of the same family of products.
     ➡ Universal life insurance products must belong to the same generation of products.
     ➡ The effective date of the policy to which the association will be made must be prior to that of the coverages that will be associated.
      Insured (last and first name)                                              Coverages to associate

      ______________________________________________________________________     ____________________________________________________________________________

      ______________________________________________________________________     ____________________________________________________________________________

      ______________________________________________________________________     ____________________________________________________________________________


23.3 The associated insurance will be transferred and assigned to the owner of policy no. _________________________________________________
     ➡ The policyowner(s) of the above-mentioned policy must agree to the addition to their policy by signing hereinbelow.
     ➡ If the contract contains the CAD, CID, CADE, WP or WPDis benefits, attach form F3A for the policyowner.
             I agree to the addition of the associated insurance to my insurance policy. The addition will
             take effect when the transaction is accepted by Industrial Alliance/Industrial Alliance Pacific.
                                                                                                                                                 IMPORTANT
                                                                                                                                       Please also fill out the SIGNATURES
                                                                                                                                       section herein-below to complete
             ___________________________________                 ___________________________________                                   this transaction.
             Policyowner                                         Policyowner


DETAILS AND SPECIAL INSTRUCTIONS

___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________

                                                                                  SIGNATURES
 We agree that this request is an integral part of the modified contract and that the modification takes effect as of the acceptance of the request by the Company inasmuch as
 the latter has been accepted without modification, the premium has been paid and no change has taken place in the insurability of the proposed insureds since the signing of
 the request. We acknowledge having read the interim insurance agreement in the event of death or critical illness and having understood the terms thereof.


 Signed at __________________________________________________________________ this _____________ day of ___________________________ 20_________


 X
 ____________________________________            X
                                                ____________________________________               X
                                                                                                  ____________________________________         X
                                                                                                                                              ____________________________________
 Agent                                          Irrevocable Beneficiary/Assignee                  Policyowner/Authorized person               Policyowner/Authorized person


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                                                                         Contract no.
                                                                                                                                              • INTERIM INSURANCE                                                  F4A-17
                                                                                                                                                AGREEMENT IN CASE OF
                                                                                     _                                          _               DEATH OR CRITICAL ILLNESS

 24. INTERIM INSURANCE AGREEMENT IN CASE OF DEATH OR CRITICAL ILLNESS
The interim insurance coverage applies to each proposed insured whose name appears on the application           •    If any answer given on the application, the medical examination report or any other document or
bearing the same number as this agreement, according to the conditions hereunder.                                    process used to collect information with regards to the risk is incomplete or false and if a true answer
The Company offers insurance coverage as of the date the application bearing the same number as this                 had been given, the application would not have been accepted as requested;
agreement is signed, when an amount equal to 1/12 of the annual premium is paid with the application,           •    If the proposed insured is less than 15 days old or more than 71 years old on the nearest birthday
including any payment made upon enrolment in the PAC plan. The amount paid will be applied to pay for                when the application is signed;
the policy on the policy issue date.                                                                            •    specifically for the life insurance coverage, if the proposed insured commits suicide, or dies:
                                                                                                                     -     while committing or attempting to commit a criminal offence;
Life insurance, accidental death, accidental fracture and critical illness coverage requested on the                 -     after using drugs or medication otherwise than prescribed by a physician;
application are payable according to the terms and exclusions of the underwritten policy and the                     -     while he/she is driving a vehicle with a blood alcohol level higher than 80 milligrams per
conditions and exclusions hereunder.                                                                                       100 millilitres of blood;
MAXIMUM AMOUNT OF INSURANCE                                                                                     •    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
The maximum coverage for all interim insurance coverages in-force for all applications signed for the same
                                                                                                                     or he/she does not survive 30 days after the date of the diagnosis.
proposed insured is $500,000 including accidental death coverage.
                                                                                                                The death benefit for the Home Protection Plan is not payable if the critical illness benefit is payable.
Policy replacement
If the requested insurance replaces a contract of the Company whose face amount is lower than the face          TERMINATION OF THE INTERIM INSURANCE AGREEMENT
amount of the requested insurance, the amount of the interim insurance is the difference between the            The interim insurance agreement terminates on the date that the first of the following events occurs:
requested face amount on the application and the face amount of the replaced contract.                          •    The application is accepted without modification;
                                                                                                                •    45 days after the application has been accepted with a modification such as a change of class, an
If the requested insurance replaces a contract of the Company whose face amount is greater than or equal to
                                                                                                                     extra premium, a rate change or a change in the insurance amount;
the face amount of the requested insurance, no amount is payable under this interim insurance agreement.
                                                                                                                •    The acceptance by the applicant of a policy issued with a modification;
CONDITIONS AND SPECIFIC EXCLUSIONS                                                                              •    The application is denied by the Company, regardless of whether or not the applicant has been
This agreement does not include disability coverage and changes of insurability that occur before the date           advised;
the application is accepted other than if death has occurred or a critical illness has been diagnosed.          •    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 interim insurance agreement is null and void if any of the following cases apply:                                the application was signed.
•    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;                    The death benefit and critical illness benefit are payable according to the designations made on the
•    If the proposed insured had consulted a physician in the 30-day period before the application was          application and the accidental fracture benefit is payable to the applicant.
     signed for a reason other than pregnancy;
 Signed at                                                  this                                       day of                                   20             Agent’s signature




 PRE-NOTICE FROM THE MEDICAL INFORMATION BUREAU
Information regarding your insurability will be treated as confidential. Industrial Alliance Insurance          Upon receipt of a request from you, the MIB will arrange disclosure of any information it may have
and Financial Services Inc./Industrial Alliance Pacific Insurance and Financial Services Inc. and its           in your file. If you question the accuracy of information in the MIB’s file, you may contact them and
reinsurers may, however, make a brief report thereon to the Medical Information Bureau (MIB), a                 request a correction. The address of the MIB’s information office is: Medical Information Bureau,
non-profit membership organization of life insurance companies, which operates an information                   330 University Avenue, Toronto, Canada, M5G 1R7; telephone: 416 597-0590. Information about
exchange on behalf of its members. If you apply to another MIB member company for life or health                the MIB may be obtained on its website at www.mib.com.
coverage, or a claim for benefits is submitted to such company, the MIB, upon request, will supply              Industrial Alliance Insurance and Financial Services Inc./Industrial Alliance Pacific Insurance and
such company with the information it may have in its files.                                                     Financial Services Inc. 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.

 NOTICE                                                                                                             DISCLOSURE STATEMENT
In order to consider your request for insurance, it is possible that we may request additional information.     The transaction represented by this application is between the applicant and Industrial
A representative from an inspection company may contact you to obtain information concerning your               Alliance/Industrial Alliance Pacific. The licensed Agent/Agency soliciting this application is an
personal and financial status. A doctor or registered nurse from a paramedical organization may be              independent contractor representing Industrial Alliance/Industrial Alliance Pacific and will receive
asked to complete a medical examination and/or collect a blood or urine sample. The analysis will be            compensation from Industrial Alliance/Industrial Alliance Pacific when the transaction is complete.
used to determine the presence of different anomalies such as cholesterol, diabetes, hepatic disorders          The applicant is not obligated to transact additional business with the Agent/Agency, Industrial
or the use of medication, drugs, nicotine, and infection by the AIDS virus.                                     Alliance/Industrial Alliance Pacific, or any other organization as a condition of this application.
Before collecting this blood or urine specimen, your written consent will be required.

 CONSTITUTION OF A FILE AND PROTECTION OF PERSONAL INFORMATION
In order to ensure the confidentiality of your personal information, Industrial Alliance/Industrial             Industrial Alliance                              Industrial Alliance Pacific
Alliance Pacific will establish a file, the object of which is to offer you insurance, annuity and credit       Insurance and Financial Services Inc.            Insurance and Financial Services Inc.
products and other complementary services according to your needs, and in which the necessary                   Information Access Officer                       Privacy Officer
information gathered for this object will be kept.                                                              1080 Grande Allée West                           2165 Broadway West
Only the employees or representatives of the company who need this information as part of their                 PO Box 1907, Station Terminus                    PO Box 5900
duties, or any other person whom you authorize, will have access to this file. Your file will be kept           Quebec City, QC G1K 7M3                          Vancouver, BC V6B 5H6
in Industrial Alliance’s/Industrial Alliance Pacific’s offices.                                                 Industrial Alliance/Industrial Alliance Pacific may establish a list of its clients for its own
You are entitled to access the personal information contained in this file and, if necessary, to have           commercial prospecting purposes or that of member companies of the Industrial Alliance group.
it rectified by sending a written request to the following address:                                             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 or Privacy Officer at the addresses indicated above.




                                                                                                                                                                                           Detach and submit to client

                                                                                                                                                                                                                     F4A(11-04) PDF

								
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