Fillable APPLICATION FOR TERM CONVERSION

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APPLICATION FOR TERM CONVERSION

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The APPLICATION FOR TERM CONVERSION form is 5 pages long and contains:

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  • 35 check-boxes
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Country of origin: CANADA
File type: PDF

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Purpose of the Converted Policy
Please indicate the client’s stated reason(s) for purchasing this converted policy (not all policies are suitable for all purposes).
£ Short term savings £ Retirement/Long term savings £ Business/Key person protection/Buy sell agreement
£ Income creation £ Gift £ Income/Family protection
£ Legacy/Inheritance/Estate protection £ Mortgage/Debt Insurance £ Education purposes
£ Other
APPLICATION FOR TERM CONVERSION
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
Current term policy number to be converted
Policy owner(s)
Policy owner for the converted policy will remain the same as the current term policy.
Beneficiary: Note: Beneficiary(s) for coverted policy will remain the same as the current term policy.
Occupation and duties (if retired, indicate former occupation):
Date of birth: (dd/mm/yyyy)
(Full/Partial) All conversions must meet current product minimums and meet all product and benefit availability guidelines. For any amount of
insurance or benefits in addition to the amount available for conversion or Child Rider Conversions, a full application (Form 350)
must be completed.
Please complete a separate application for each Life Insured.
Coverage Details for Converted Policy
The Converted Policy will be issued according to the signed illustration submitted with this application. The signed illustration must
be submitted with the Application to provide required information to complete the conversion process. The illustration must use
Equitable Life’s most current software, include any ratings from the current term policy, and the intended billing method. (annual/
monthly) Universal Life policies will be issued with the Investment Allocations indicated under the Interest Rate Assumptions section of
the signed Equitable Sales Illustration for the converted policy. (If no Investment Allocations are indicated the converted policy will be
issued with Daily Interest Account.)
1616(2018/06/22) Page 1 of 5
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.668.4095 Fax 519.883.7404
Name of insured (First, Middle, Last)
Insured’s date of birth: (dd/mm/yyyy)
Current term coverage amount (A)
Amount of term coverage to be converted. (Must equal submitted illustration.) (B)
Amount of current term coverage to be carried over* (C)
Amount of current term coverage to be cancelled (D)
Amount of current term coverage to remain on original term Policy or rider (E)
(A) must equal (B) + (C) + (D ) + (E)
If less than 50% of the current term coverage is being converted - A term rider can be added with a maximum face amount equal to the
remaining permanent coverage.
All
Amounts
must
meet plan
minimums
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
1616(2018/06/22) Page 2 of 5
APPLICATION FOR TERM CONVERSION
Declaration, Acknowledgement, Agreement and Authorization
1. For jointly owned Policies the terms “I”, “me” and “my” refer to both owners of the contract.
2. I have received from my advisor information concerning the conversion of my current term insurance policy to a permanent insurance
policy and the options available to me. I have reviewed the illustration for my converted policy attached to this application.
My signature on that illustration and this Application is my authorization to convert my current term policy. I authorize Equitable Life
of Canada
®
to use the Selected Coverage, Dividend Options, Premium Type and Investment and Shuttle Account allocations as
documented on the attached illustration. I agree that my converted policy will be issued on that basis.
3. If I do not return the converted policy to Equitable Life of Canada within 21 days of its delivery to me, I will be deemed to have
accepted it. The conversion from my current term policy to the converted policy will be final.
4. I authorize and consent to Equitable Life of Canada, their agents and reinsurers to collect, use, retain and disclose all
information necessary for the administration of converted policy. I understand the Equitable Life of Canada Privacy Policy is
available at www.equitable.ca. I authorize Equitable Life of Canada to use my SIN or other tax identification number for tax
reporting and identification purposes.
5. I understand that Equitable Life of Canada is relying on the accuracy of the application information that it received for my current
term policy. If I made a material misrepresentation when I applied for my current term policy, Equitable Life of Canada could rescind
and cancel the converted policy. I certify that the information provided on this application is current, correct and complete. For
Universal Life and Whole Life policies, I will notify Equitable Life within 30 days of any change to my tax residency, US citizenship
status or tax identification numbers.
6. I agree and direct that the owner, beneficiary designations and any trustee appointment(s) shown in the records of Equitable
Life of Canada on the date of the conversion of the current term policy will be designated and appointed exactly the same for
the converted policy. To change these designations and appointments, I must complete, sign and submit a beneficiary or owner
change form.
7. I authorize Equitable Life of Canada to withdraw the new premium as outlined on the illustration for the converted policy, and
understand that it may be higher or lower than my current premium for the current term policy. I waive my right to notice before the
withdrawal is made and my right to notice of the change in the automatic withdrawal amount. The terms and conditions of my
existing Pre-Authorized Debit agreement apply to the converted policy.
(city) (province) (day) (month)
Signed at this of 20 .
Signature(s) of Owner(s)
If policy is jointly owned, all owners’ signatures required
Do you want to back date to save age? £ Yes £ No
Conversions can be back dated up to 3 months to retain age for universal life plans and 6 months for whole life plans.
Premium Payments: £ Annual (Cheque or Online Payment) £ Monthly (use existing pre-authorized debit for current term
policy - Universal Life draw date must be same as issue date)
£ If new banking, attach completed Pre-Authorized Debit Form (378). In the Section ‘Policy Number(s)’ indicate: Application
for Conversion from Policy # dated , 20 .
Note: If the deposit is equal to or greater than $100,000, please complete section 1 and section 2 on Form
1027-Additional/Updated Customer information form. In the Section ‘Policy Number’ indicate: Application for Conversion from
policy #xxxxxxxxx dated dd/mm/yyyy.
APPLICATION FOR TERM CONVERSION
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
1616(2018/06/22) Page 3 of 5
Applicant/Owner Declaration
Policy Owner: check all of the options that apply to you.
I am a tax resident of Canada: Provide Social Insurance Number (SIN):
I am a tax resident or citizen of the United States: Provide Taxpayer Identification Number (TIN):
I am a tax resident in a jurisdiction other than Canada or the United States:
Jurisdiction of tax residence Taxpayer Identification Number (TIN):
If you do not have a TIN for a specific jurisdiction, choose one of the following reasons:
a) I will apply or have applied for a TIN but have not yet received it
b) My jurisdiction of residence does not issue TINs to its residents
Other reason:
Name (first, middle initial, last)
Confirmation by advisor (choose one):
I, the advisor, have held and viewed the original photo identification. Provide details:
Identification Type: Expiry Date (dd/mm/yyyy):
Identification Number: Date Advisor Verified (dd/mm/yyyy):
Issuing Jurisdiction / Country:
I, the advisor, have followed the alternative identification instructions, including reviewing two original documents as
set out in the instructions. Copies of the two documents are attached with this application.
Policy Owner Verification (Use Business Information Form 594, if owner is a corporation or business entity)
Choose one of the following: driver’s licence, provincial photo card (excluding provincial health cards), passport,
citizenship card, permanent resident card, or certificate of Indian status card. If you do not have one of the pieces
of identification indicated, please go to www.equitable.ca/go/alternative-identification for information on our
alternative identification requirements.
Third Party - To be completed for all applications
In submitting this application, is the Owner acting on behalf of a Third Party?
£ NO £ YES - complete either the “Individual Third Party” or “Business / Entity Third Party” section as applicable on
form #31– Third Party Information.
Your answer should be “Yes” if someone other than the Owner or Insured will be paying the premium or has/will have an
ownership interest in the converted policy. Examples include a power of attorney signing on behalf of the owner, someone
other than the owner or insured paying premiums, or a corporation having use or access to the converted policy values.
APPLICATION FOR TERM CONVERSION
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
1616(2018/06/22) Page 4 of 5
Joint Applicant/Owner Declaration
Policy Owner: check all of the options that apply to you.
I am a tax resident of Canada: Provide Social Insurance Number (SIN):
I am a tax resident or citizen of the United States: Provide Taxpayer Identification Number (TIN):
I am a tax resident in a jurisdiction other than Canada or the United States:
Jurisdiction of tax residence Taxpayer Identification Number (TIN):
If you do not have a TIN for a specific jurisdiction, choose one of the following reasons:
a) I will apply or have applied for a TIN but have not yet received it
b) My jurisdiction of residence does not issue TINs to its residents
Other reason:
Name (first, middle initial, last)
Confirmation by advisor (choose one):
I, the advisor, have held and viewed the original photo identification. Provide details:
Identification Type: Expiry Date (dd/mm/yyyy):
Identification Number: Date Advisor Verified (dd/mm/yyyy):
Issuing Jurisdiction / Country:
I, the advisor, have followed the alternative identification instructions, including reviewing two original documents as
set out in the instructions. Copies of the two documents are attached with this application.
Joint Policy Owner Verification (Use Business Information Form 594, if owner is a corporation or business entity)
Choose one of the following: driver’s licence, provincial photo card (excluding provincial health cards), passport,
citizenship card, permanent resident card, or certificate of Indian status card. If you do not have one of the pieces
of identification indicated, please go to www.equitable.ca/go/alternative-identification for information on our
alternative identification requirements.
I have provided the following information to the owner: (a) the company(ies) I represent (b) that I receive compensation (including
commissions) for the sale of life and health insurance products (c) that I may receive additional compensation in the form of bonuses,
conferences or other incentives and (d) any actual or potential conflict of interest I may have with respect to this transaction.
APPLICATION FOR TERM CONVERSION
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
1616(2018/06/22) Page 5 of 5
Advisor Information
Advisor Instructions
MGA name and email address MGA number
Advisor name (Servicing) Advisor number Commissions %
Advisor name Advisor number Commissions %
Advisor email (Servicing) Advisor phone number
Are you related to the Policy Owner? £ Yes £ No If “Yes” provide details
Advisor Signature Signed at Date
Please note: Equitable Life
®
cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be
vulnerable to interception. As a result, Equitable Life is not responsible for any loss or damages you may incur if your information is intercepted
and misused. If you would prefer to submit your information by another means, please contact us at 1.800.722.6615.
Policy
Owner:
Owner will remain the same as the current term policy. If an owner change is requested, complete a Change
of Ownership Form #671NOC. In the section policy number(s) indicate: Application for conversion from policy
#......... dated dd/mm/yyyy
Beneficiary: Beneficiary(s) will remain the same as the current term policy. If beneficiary(s) are to be different please complete
Beneficiary Change Request form #671BCF. In the section policy number(s) indicate: Application for conversion from
policy #xxxxxxxxx dated dd/mm/yyyy.
If there is an irrevocable beneficiary on the current term policy, authorization from that individual is required to
proceed with the conversion.
Premium
Payments:
Annual – Payment required before processing. A term conversion is a continuation of the original policy and
therefore cannot be issued C.O.D.
Monthly – Use existing banking from current term policy.
Monthly – New banking – complete Pre-Authorized Debit Plan Authorization form #378. In the section policy
number(s) indicate: Application for conversion from policy #xxxxxxxxx dated dd/mm/yyyy.
Universal Life withdrawal date must be the same as issue date
Note: If a future withdrawal date is requested the application will be held until the withdrawal date.
If payor is not the owner, submit completed Third Party Information form #31
If there is an assignment or bankruptcy on the current term policy, release of assignment/bankruptcy or authorization from assignee
is required.
Note: No charges apply for conversion processing. A $50 Charge will apply to reverse the conversion. The reversal is only
available within 21 calendar days from the date of issue of the converted policy.
Eligible
Conversion
Options
Convertible to Notes
Equimax
®
Participating Whole Life
Equation Generation
®
IV
Must convert to same coverage type (e.g. Joint to Joint, Single to single)
Children’s Protection Rider can be carried if applicable.
For detailed instructions please refer to Equitable Life’s Guide to Application for Term Conversion Form #1616 – Guide
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APPLICATION FOR TERM CONVERSION

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Completed 27 February 2021

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