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- 5/2/2012
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Document Sample
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
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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
Validate and Print
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
Validate and Print
• 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
F4A(11-04) PDF
Validate and Print
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 %
____________________________________________________________ _________________________
____________________________________________________________ _________________________
____________________________________________________________ _________________________
____________________________________________________________ _________________________
F4A(11-04) PDF
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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
F4A(11-04) PDF
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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.
F4A(11-04) PDF
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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
F4A(11-04) PDF
Validate and Print
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
F4A(11-04) PDF
Validate and Print
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
