Fillable CLAIMANTS STATEMENT FOR INDIVIDUALS SAVINGS & RETIREMENT (Equitable Life of Canada)

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CLAIMANTS STATEMENT FOR INDIVIDUALS SAVINGS & RETIREMENT (Equitable Life of Canada)

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Country of origin: CANADA
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Number of each policy under which a claim is being made
Deceased’s Name (in full) Province or State of Residence
Date of Death Cause of Death
Place of Death Date of Birth Place of Birth
If any claims are being made by the estate or other entity, e.g. assignee, corporation, non-corporate entity, use the
“Claimant’s Statement — Entities (Form #1969) instead.
If you are making a claim as a trustee on behalf of a minor beneficiary, complete the Claimant Information section with the child’s
information, and enter your information in the Trustee Information section.
1516 (2021/07/02) Page 1 of 5
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
CLAIMANT’S STATEMENT FOR INDIVIDUALS — SAVINGS & RETIREMENT
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.668.4095 Fax 519.883.740 4
www.equitable.ca
Name (first, middle, last) Date of Birth (yyyy/mm/dd)
SIN and expiry or Tax Identification number Email Address
Street Address City
Province/State Postal/Zip Code Phone Number
Occupation
(job title and duties) — if not currently working, indicate former occupation
In what capacity or by what do you claim the death benefit?
(e.g. Named beneficiary, Executor or Assignee)?
Relationship to Deceased
1. CLAIMANT INFORMATION
2. PAYMENT OPTIONS
How would you like the proceeds to be paid? (Note: Not all options are available for all claims)
Paid by cheque (default if no selection is made)
Paid by direct deposit to the beneficiary’s bank account. Attach a void cheque or bank letter with the beneficiary’s name
pre-printed on the document.
For TFSA and RRIF policies where the spouse is the sole beneficiary: Elect to continue the contract as the successor annuitant
Deposit to Equitable Life policy #
Deposit to a new Equitable Life savings policy. Complete a new application with an advisor. If you require an advisor please
contact our Customer Service team at 1.800.668.4095.
Payout Annuity contracts only: Payments to continue to beneficiary. Restrictions apply.
Transfer to another financial institution (please provide a transfer form)
Other:
1516 (2021/07/02) Page 2 of 5
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
Equitable Life is required to verify the Claimant’s identity (or the identity of the Trustee for the Claimant) on policies where the death benefit is
equal or greater than $10,000. If you meet these criteria (or you are unsure), please provide your consent to having your identity verified by a
third party by checking the box below, and provide the identification documents as instructed.
I consent to Equitable Life verifying my identity through a third-party service provider.
You are required to provide two forms of identification. Each of the documents must be from a different category below (that is, no more than
one document from any one of the categories). The documents should be from a Canadian source unless otherwise indicated.
4. IDENTITY VERIFICATION
CLAIMANT’S STATEMENT FOR INDIVIDUALS — SAVINGS & RETIREMENT
CATEGORY A
(must include name and address)
CATEGORY B
(must include name and date of birth)
CATEGORY C
(must include name and account
information)
Government issued photo identification
(excluding provincial health cards)
– different from Category B document
Government issued photo identification
(excluding provincial health cards)
– different from Category A document
Bank account statement
Benefits statement: Federal, Provincial,
Territorial or Municipal
Birth Certificate Loan account statement
Canada Pension Plan statement
Marriage Certificate /
Divorce documentation
Credit card statement
Provincial Vehicle Registration
Insurance company document
(home, auto, life excluding Equitable Life)
Letter from bank, trust company or credit
union confirming account
Municipal Property Tax Assessment Permanent Resident Card
Utility bill (e.g. hydro, phone, cable, etc.) Citizenship Certificate
Investment account statement (e.g. RRSP,
securities account, excluding Equitable Life)
Investment account statement
(e.g. RRSP, GIC, excluding Equitable Life)
Travel Visa issued by a foreign
government
Temporary Driver’s Licence (non-photo)
Name (first, middle, last) Date of Birth (yyyy/mm/dd)
Street Address City
Province/State Postal/Zip Code Phone Number
Occupation (job title and duties) — if not currently working, indicate former occupation
3. TRUSTEE INFORMATION (if applicable)
6. POLITICAL POSITIONS
The following section is required when the death benefit is non-registered and ≥$100,000. If you meet these criteria (or you are unsure),
please complete the section.
For the purposes of this question:
• “Claimant” means the person who is entitled to receive the death benefit on the policy.
• “Close relative” means the Claimant’s Spouse, sibling, parent, Spouse’s parent, child, or child’s Spouse.
• “Close associate” means an individual who is closely connected to the Claimant for personal or business reasons.
• “Spouse” means the Spouse or common law partner.
Does the claimant, any of the claimant’s close relatives or any of the claimant’s close associates hold, or have they ever held, any of the positions
listed below:
No – go to next section Yes – indicate the position held below
Position in Canada or in another country
Note: For positions in Canada, list only the positions held in the past five years. For all other countries, list all such positions that have ever been
held.
Head of state or head of government (including Governor General
and Lieutenant Governor)
President of a state-owned company or bank (including a corporation
that is wholly owned by a federal or provincial government)
Member of the executive council of government or member of a
legislature (including the Senate, House of Commons or a provincial
legislature)
Head of a government agency
Judge (in Canada only, must be a judge of an appeal court)
Head of an international organization that is established by the
governments of countries or the head of an institution of any such
organization (indicate only if the position was held
in the past five years)
Deputy Minister (or equivalent)
Leader or President of a political party in a legislature
Ambassador or ambassador’s attaché or counsellor
Military General (or higher rank)
Mayor of a Canadian municipality (does not include mayors in
countries other than Canada)
If you answered “Yes” to the question above, complete the following information:
What is the name of the person who holds or held the position? What is the title of the position held?
Position held from:
(starting year)
to
(ending year)
In what country was the position held?
1516 (2021/07/02) Page 3 of 5
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
CLAIMANT’S STATEMENT FOR INDIVIDUALS — SAVINGS & RETIREMENT
If your address is outside of Canada, or the money is to be sent outside of Canada, please complete this section.
I am a tax resident of Canada
I am a tax resident or citizen of the United States:
Provide Taxpayer Identification Number (TIN) or functional equivalent:
I am a tax resident in a jurisdiction other than Canada or the United States:
Jurisdiction of tax residence Taxpayer Identification Number (TIN) or functional equivalent:
If you do not have a TIN or functional equivalent 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:
5. DECLARATION OF TAX RESIDENCE (For non-registered only)
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
CLAIMANT’S STATEMENT FOR INDIVIDUALS — SAVINGS & RETIREMENT
1516 (2021/07/02) Page 4 of 5
I certify that the information given in this statement is true, correct and complete.
Dated at this day of
Signature of Claimant Witness
By providing this or other claim forms to the claimant, the Company does not admit to any liability or waive any of its rights.
A limitation period provision describes the time period in which you may commence a proceeding for recovery of policy benefits.
This time period is set out in provincial insurance legislation or other legislation that applies to your claim.
Additional Forms Required
For all claims: If you have not previously provided Equitable Life with the deceased person’s death certificate, please submit it with this form.
6. POLITICAL POSITIONS (continued)
With what organization, government or institution was the
position held?
How is this person related to the claimant?
The person is the claimant
Close relative (relationship):
Close associate (relationship):
What is the claimant’s source of wealth? (Where a Trustee has been named, specify the Trustee’s source of wealth):
Salary or Earned Income Investment Income
Property Income/Holdings Inheritance
Business Income Other
Lottery
INSTRUCTIONS
Contact our Head Office at 1.800.668.4095 for information or assistance in completing this statement and providing proof of claim.
COMPLETING THE CLAIMANT’S STATEMENT
1. If the policy is payable to a named beneficiary or beneficiaries:
• This statement should be completed by the named beneficiary, unless a minor. If there is more than one beneficiary, each beneficiary should
complete a separate statement.
• If any named beneficiary is a minor, this statement should be completed on behalf of the minor beneficiary by the guardian or other
person authorized by law to deal with the minor’s property.
• If any named beneficiary is deceased, proof of death of such beneficiary must be provided.
2. If the policy is payable to the estate of the deceased:
• The cheque will be made payable to the Estate of the deceased.
3. If the policy is assigned:
• A statement should be completed by the assignee as well as the beneficiary. Payment will be made to the assignee.
4. Claimant’s Social Insurance Number/Tax ID (IRS) Number:
• This information is required from the claimant as it may be required to report any taxable income paid to the claimant. If the claimant has
never been assigned a social insurance number, insert “No number”. If the estate of the deceased is the claimant, the deceased’s Social
Insurance Number should be inserted.
5. If you have concerns about your claim, go to www.equitable.ca/en/get-in-touch and click on the Share a concern under
Other Contact Information at the bottom of the screen. There you will find information on how to file a complaint, including
independent review by the OmbudService for Life & Health Insurance, provincial insurance regulators and the courts.
Please note: While using the Internet and e-mail is convenient, sending confidential and personal information through the Internet is not secure. E-mail is
vulnerable to interception. If this form contains confidential or personal information, you should consider sending this form to us other than by e-mail.
You can contact us at 1.800.668.4095 for contact information. Equitable Life is not responsible for any loss or damages you may incur or if your information is
intercepted and misused, if you send confidential or personal information to us over the Internet.
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
CLAIMANT’S STATEMENT FOR INDIVIDUALS — SAVINGS & RETIREMENT
1516 (2021/07/02) Page 5 of 5
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Completed 4 February 2022

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