Fillable 1. CONTRACT DETAILS PIVOTAL SELECT - WITHDRAWAL REQUEST (Equitable Life of Canada)

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1. CONTRACT DETAILS PIVOTAL SELECT - WITHDRAWAL REQUEST (Equitable Life of Canada)

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PIVOTAL SELECT - WITHDRAWAL REQUEST
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.668.4095 T 519.886. 5210 F 519.883.740 4
www.equitable.ca
1. CONTRACT DETAILS
First Name Last Name Contract Number
1319(2014/03/24) Page 1 of 1
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
3. TERMS AND CONDITIONS
4. SIGNATURES
2. WITHDRAWAL DETAILS
Fund Number q All OR q $ (You must check one)
Fund Number q All OR q $
(You must check one)
Fund Number q All OR q $
(You must check one)
Fund Number q All OR q $
(You must check one)
Please make my payment using: q Banking on File OR q New Banking (attach a VOID cheque to this form)
A minimum withdrawal of $500 is required. If making a partial withdrawal: A minimum of $50 must be maintained in a segregated fund or it will be closed and all money in the fund paid out,
and a minimum of $500 must be maintained in the policy or it will be terminated and all money in the policy paid out.
Please make the withdrawal as: q Net OR q Gross
Please withdraw my funds from:
• Thewithdrawaltransactioncouldnegativelyaffectthevalueofthecontract’sMaturityandDeathBenetGuarantee.
• Awithdrawalmayresultinacapitalgainoracapitallosssinceitcreatesataxabledisposition(non-registeredcontractsonly).
• Youmaybechargeddeferredsalescharges(DSC)forthewithdrawalportionofthistransaction.
Yoursignaturebelowstatesyouagreewithallinformationandinstructionssetoutabove:
Date: ContractOwner’sSignature: Date: JointContractOwner’sSignature:
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1. CONTRACT DETAILS PIVOTAL SELECT - WITHDRAWAL REQUEST (Equitable Life of Canada)

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Completed 1 February 2022

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