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Canada Protection Plan

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The Canada Protection Plan form is 17 pages long and contains:

  • 9 signatures
  • 11 check-boxes
  • 340 other fields

Country of origin: CANADA
File type: PDF

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Distributed by
Canada Protection Plan
Application for Life Insurance
™
LIFE COVERAGE
Application Checklist
Plan
Availability
Ensure that all applicable questions are completed before submitting.
Print legibly in dark ink. Do not use “ditto” marks. Do not draw a line
through any questions or answers. Do not make erasures or use liquid
paper. If you cross out an error, each person signing the application
must initial it.
Attach an illustration for each policy applied for.
Submit applicable disclosure forms if replacing existing life insurance.
Note that the initial premium will be applied on the policy date, which
will be the date the policy is actually issued.
If premium payment is annual, ensure that the initial premium is paid
with the application. COD applications are NOT allowed.
If the initial premium is to be paid by cheque, include a current
dated cheque payable to Foresters Life Insurance Company
with the same date as the application.
If the initial premium is to be paid by credit card, the frequency
of premium payments must be annual.
If premium payment is monthly by Pre-Authorized Debit (PAD),
include a void cheque or complete the banking information on
page 6 (see sample cheque below). For monthly (PAD) payment
method, there is no premium debit for the first month.
Each Advisor MUST have a valid licence and E&O on file with
Canada Protection Plan or copies must be attached to this
application.
Notify your client that they may receive a verification call from the
Insurer to verify the information on their application.
18 — 60
61 — 75
18 — 60
61 — 80
18 — 60
61 — 80
18 — 60
61 — 80
18 — 80
18 — 80
18 — 80
18 — 60
61 — 75
18 — 60
61 — 80
18 — 60
61 — 80
18 — 60
61 — 80
18 — 80
18 — 80
18 — 80
$10,000
$5,000
$10,000
$5,000
$10,000
$5,000
$10,000
$5,000
$50,000
$500,000
$25,000
2
$10,000
$5,000
$10,000
$5,000
$10,000
$5,000
$10,000
$5,000
$50,000
$500,000
$25,000
2
18 — 70
18 — 60
18 — 55
18 — 60
18 — 70
18 — 60
18 — 55
18 — 60
$25,000
2
$25,000
2
$25,000
2
$25,000
2
$25,000
2
$25,000
2
$25,000
2
$25,000
2
$50,000
$50,000
$75,000
$50,000
$350,000
1
$350,000
1
$500,000
1
$350,000
1
$1,000,000
1
$1,000,000
1
Maximum depends on age
and plan — see above
$50,000
$50,000
$75,000
$50,000
$350,000
1
$350,000
1
$500,000
1
$350,000
1
$1,000,000
1
$1,000,000
1
Maximum depends on age
and plan — see above
10 Year Term
20 Year Term
25 Year Term
25 Year Decreasing Term
1
2
3
4
5
|
|
|
|
|
6
7
8
|
|
|
Canada Protection Plan™ | Application Checklist
105941 (06/20)
Base Plan Issue Ages Minimum Maximum
Maximum depends on
age and plan
— see above
$5,000, $10,000 or $15,000
Lesser of one times
coverage and $10,000
Lesser of five times
coverage and $250,000
$25/day, $50/day or $100/day
18 — 60 (parent)
18 — 65
18 — 65
Child Term Benefit
Hospital Cash Benefit
Accidental Death Benefit
Simplified Elite Life
Preferred Life
Preferred Elite Life
T100
(available as Deferred Elite, Simplified Elite, Preferred and Preferred Elite)
Deferred Elite Life
Deferred Life
Guaranteed Acceptance Life
Account Number
Financial Institution NumberTransit Number
Cheque Number
Base Plan or Rider (available as Deferred Elite, Simplified Elite, Preferred and Preferred Elite)
Rider Only
Maximums shown are for combined
coverage under all Life and Term
policies of same Plan category.
Minimum is $50,000 for a
Preferred term plan or rider or a
Preferred Elite term rider, and
$500,000 for a Preferred Elite
term plan.
To ensure priority service:
1
2
Insured Owner Other
Yes No
— complete this section
Yes No, applying for membership
Name
Primary
Work / Other
Street Name & Number Apartment Number
First LastMiddle
105941 (06/20) | 1
Application for Life InsuranceInsured, Owner, Beneficiary and Payor 01
In this application, Insured
means the person proposed to
be the insured.
Complete Owner details only
than Insured
If the Owner is a corporation, the
signature must be accompanied by
either the company name and title
company seal.
SIN required only if applying for
permanent life insurance
(except for T100).
Total % share must equal
100% for Primary and 100%
for Contingent Beneficiaries.
Important: Each beneficiary is
revocable unless indicated otherwise.
However in Quebec, the designation
of a legally married spouse of the
Owner is irrevocable unless expressly
indicated to be revocable.
Complete Payor details only if
Canada Protection Plan™ | Application for Life Insurance
Date of Birth
MM / DD / YY
Street Name & Number Apartment Number
U.S. Tax Identification Number
Telephone
Primary
Work / Other
Telephone
Country of Birth Canadian Citizen
1
Permanent Resident
1
Work Permit/Study Permit
1
Insured
Other
— complete this section
P C
P C
P C
R I
R I
R I
Full Legal Name, or Corporation/Entity
3
Full Name
Full Legal Name, or Corporation/Entity
If a beneficiary is a minor: In all provinces except Quebec, a trustee should be named to receive funds on the minor’s behalf.
In Quebec, the proceeds payable to a minor will be paid to the parent(s) (or legal guardian, if applicable).
Relationship to Insured
(or to Owner in Quebec)
Beneficiary Name
Date of Birth
MM/DD/YY
%Share
Revocable (R)
Irrevocable (I)
Primary (P)
Contingent (C)
Relationship to Owner
Social Insurance Number
2
Social Insurance Number
4
Email (Optional) Occupation
Driver's Licence (or Gov't Issued Photo ID # and Type)
Expiry Date (MM/DD/YY)Province/Territory of IssueNumber (and type)
Expiry Date (MM/DD/YY)Province/Territory of IssueNumber (and type)
Driver's Licence (or Gov't Issued Photo ID # and Type)
Address
Best date and time to call for verification,
if applicable (be specific):
Are you a Foresters member?
City / Town
Date Time
Province/Territory
Postal Code
Street Name & Number Apartment Number
Address
City / Town Province/Territory
Postal Code
MM / DD / YY
Address
City / Town Province/Territory
Postal Code
INSURED
OWNER
CONTINGENT OWNER
BENEFICIARY
PAYOR
Relationship to Insured
Trustee Name
Date of Birth
Relationship to Owner
Email (Optional)
Owner is:
Payor is: Relationship to Insured
Name of Country(ies) Tax Identification Number(s)
Are you a U.S. Resident for tax purposes, or a U.S. citizen, and/or a resident of another country for tax purposes?
If YES, provide and/or and
Owner’s International Tax Status02
Complete only if applying for
permanent life insurance
(except for T100).
Male
Female
1
3
4
!
Must be a Canadian Citizen,
Permanent Resident or with a valid
work or study permit to apply.
Insured on a work or study permit
is $250,000.
The maximum amount for an
SIN required only if the Insured will
be the Owner and is applying for
permanent life insurance
(except for T100).
2
105941 (06
/20) | 2
Canada Protection Plan™ | Application for Life Insurance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Insurer
Amount Plan
1 | Within the past 12 months, have you used by any means, a substance or product containing tobacco or nicotine
(excluding cigars), or have you smoked (including electronic vaporizer or “vaping”) marijuana more than four times per week?
If YES, smoker rates applicable
1 | Are you currently incapable of independently carrying out two or more of the basic activities of daily living such as
getting up, walking, washing, toileting, dressing or feeding?
2 | Are you currently a resident of a long-term care facility, nursing home, nursing facility,
or assisted living residence?
3 | Are you in need of an organ transplant, on a waiting list for an organ transplant or the recipient of an organ transplant
(excluding corneal transplants)?
4 | Within the past 30 days, have you been admitted to a hospital for more than 48 hours (excluding pregnancy)?
5 | Within the past 60 days, have you been advised by a physician:
a. Of any abnormal diagnostic tests?
b. To have surgery or a diagnostic test or special test of any type?
c. To consult with a physician, medical institution or specialist that has not yet been completed?
6 | Have you ever been diagnosed with a life threatening, critical or terminal condition for which a physician has
estimated that you have 24 months or less to live?
7 | Have you ever had, been told you have, or been treated for Acquired Immunodeficiency Syndrome (AIDS)
or have you ever tested positive for Immunodeficiency virus (HIV)?
9 | Have you ever had, been treated for, or been diagnosed prior to age 40, with: chronic kidney disease, stroke (CVA), transie
nt ischemic
attack (TIA), aneurysm, coronary artery disease, heart bypass surgery, angioplasty, stent insertion, angina or heart attack?
10 | Within the past 12 months, have you used narcotics or barbiturates (except as prescribed by a physician), heroin,
psychoactive drugs, cocaine, crack or other similar agents, or been a resident of a drug or alcohol treatment facility?
11 | Within the past 12 months, have you been convicted of, awaiting sentencing for, incarcerated for, or on probation
12 | Is your weight greater than that indicated for your height in the following table?
8 | Within the past ten years, have you had, been told you have, been treated for, or been advised to have an
investigation, that has not yet been completed, for:
a. Metastatic cancer or more than one occurrence of cancer (excluding basal cell carcinoma)?
b. Cystic Fibrosis or a chronic respiratory condition (excluding sleep apnea) which required the continuing
administration of oxygen?
c. Dementia, Alzheimer's, Muscular Dystrophy, Huntington's Chorea or Amyotrophic Lateral Sclerosis (ALS)?
d. Congestive heart failure or cardiomyopathy?
2 | Will premiums be stopped, or coverage be reduced or discontinued, on any existing life insurance coverage or annuity
if the insurance applied for in this application is issued?
If YES, state insurer, amount and plan, and complete the Comparison Disclosure Statement or Life Insurance Replacement Declaration required in your province.
Application for Life Insurance
For all Eligibility Questions,
"You” and “Your” refer to the
Insured.
Complete these questions for
all applications. Then continue
to the next section.
Eligibility Questions 03
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1 | Within the past 12 months, have you had, been told you have, or been treated for:
a. Cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, stroke (CVA),
heart bypass surgery, angioplasty, stent insertion or more than one transient ischemic attack (TIA)?
b. Circulatory problems in the legs and/or feet (peripheral arterial or vascular disease)?
c. Chronic kidney disease, or been investigated or been advised to be investigated for polycystic kidney
disease (PKD), or have a family history of PKD and have not been investigated?
d. Liver disease such as, but not limited to, cirrhosis or hepatitis (excluding Hepatitis A or B)?
e. Cancer including, but not limited to, leukemia and lymphoma (excluding basal cell carcinoma)?
2 | Are you under age 30 and have been diagnosed with diabetes (excluding gestational diabetes) or are undergoing
investigation for diabetes or your blood sugar levels?
4’8” — 4’10”
4’11”
— 5’1”
5’2”
— 5’4”
5’5”
— 5’7”
230 lbs
247 lbs
273 lbs
300 lbs
104 kg
112 kg
124 kg
136 kg
142
— 147 cm
148
— 155 cm
156
— 163 cm
164
— 170 cm
Height
Weight
5’8” — 5’10”
5’11”
— 6’1”
6’2”
— 6’4”
6’5”
— 6’7”
328 lbs
358 lbs
389 lbs
420 lbs
149 kg
162 kg
176 kg
191 kg
171
— 178 cm
179
— 185 cm
186
— 193 cm
194
— 201 cm
Height
Weight
MEDICAL
REQUIRED
NO
MEDICAL
REQUIRED
NO
Guaranteed
Acceptance Life
Maximum $50,000
If ALL NO answers are provided,
continue to section B
If a question is answered YES
in this section, apply for
YES
NO
A
B
YES
NO
Deferred Life
Maximum $75,000
If ALL NO answers are provided,
continue to section C
If a question is answered YES
in this section, apply for
105941 (06/20) | 3
Application for Life Insurance
Canada Protection Plan™ | Application for Life Insurance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1 | Within the past 12 months, have you had, been told you have, or been treated for: bipolar disorder,
schizophrenia or psychosis?
2 | Within the past three years, have you been treated for or received medical advice or counseling
for the use of drugs or alcohol?
3 | Within the past three years, have you used narcotics or barbiturates (except as prescribed by a physician), heroin,
psychoactive drugs, cocaine, crack or other similar agents?
4 | a. Are you age 54 or under and within the past three years, have you had treatment or surgery for or been diagnosed
as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery,
angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)?
b. Are you age 55 or over and within the past two years, have you had treatment or surgery for or been diagnosed
as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery,
angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)?
5 | Are you under age 55 with diabetes that was diagnosed more than 20 years ago and is currently treated with insulin?
6 | Do you have diabetes that is currently treated with insulin and the prescribed dosage of insulin increased
within the past six months?
7 | Have you ever had, been told you have, or been treated for diabetes and any of the following: coronary artery disease,
peripheral vascular disease, tingling and loss of feeling in the extremities (neuropathy), amputation, retinopathy or
stroke (CVA)?
9 | Do you plan to travel outside North America, the Caribbean (excluding Haiti), the United Kingdom or the European Union
countries for more than 12 consecutive weeks in the next 12 months?
10 | Have you had a weight loss of 10% of body weight or more within the past 12 months other than due to
intentional dieting?
11 | Is your weight outside the range shown for your height in the following table?
NOTE: For females, deduct 5 lbs. or 3 kg from the lower range for the given height
8 | Within the past three years have you had, been told you have, or been treated for:
a. Lung cancer?
b. Colon cancer?
c. Breast cancer, cervical cancer or uterine cancer?
d. Malignant melanoma?
e. Leukemia (all types), lymphoma or multiple myeloma?
4’8” — 4’10”
4’11”
— 5’1”
5’2”
— 5’4”
5’5”
— 5’7”
79
— 185 lbs
87
— 199 lbs
94
— 215 lbs
104
— 235 lbs
36
— 84 kg
39
— 90 kg
43
— 98 kg
47
— 107 kg
142
— 147 cm
148
— 155 cm
156
— 163 cm
164
— 170 cm
Height
Weight
5’8” — 5’10”
5’11”
— 6’1”
6’2”
— 6’4”
6’5”
— 6’7”
115
— 260 lbs
125
— 282 lbs
139
— 305 lbs
149
— 333 lbs
171
— 178 cm
179
— 185 cm
186
— 193 cm
194
— 201 cm
Height
Weight
MEDICAL
REQUIRED
NO
MEDICAL
REQUIRED
NO
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
1 | Within the past 12 months, have you been told you have, been treated for, or
are you currently under investigation for multiple sclerosis?
2 | Have you ever had or been treated for cancer including, but not limited to, leukemia and lymphoma
(excluding basal cell carcinoma)?
3 | Within the past six months, have you been told you have or been treated for diabetes?
4 |
pending excluding a single DUI?
5 | Within the past two years, have you been involved in the operation of an aircraft as a pilot (scheduled commercial
pilots excluded) or involved in any hazardous sports, or do you plan to do so within the next year?
6 | Within the past two years, has your driver’s licence been suspended or revoked, or have you had
more than three moving violations within the past 12 months?
52 — 118 kg
57
— 128 kg
63
— 138 kg
68
— 151 kg
Preferred Plans*
Preferred Elite Plans*
*
You may qualify for one of these
plans subject to underwriting
requirements and approvals.
YES
NO
YES
NO
Deferred Elite Plans
Maximum $350,000
If ALL NO answers are provided,
continue to section D
If a question is answered YES
in this section, apply for
C
Simplified Elite Plans
Maximum $500,000
If ALL NO answers are provided,
continue to section E ONLY
if you wish to apply for
If a question is answered YES
in this section, apply for
D
105941 (06/20) | 4
2 | Your physician’s name Date last consulted
Address of your physician: Reason for consult
Yes No
Yes No
Yes No
1 | Have you ever been prescribed a medication that was for more than 30 days for a medical condition?
If YES, please advise the name of the prescription(s) and the nature of the medical condition they were prescribed for.
2 | Have two or more members of your immediate family (father, mother, brothers, sisters) ever had, been treated for,
or been diagnosed with cancer, heart disease, stroke (CVA) or transient ischemic attack (TIA) before the age of 60?
If YES, please provide details including age and cause of death or diagnosis of each.
1 | What is your current height and weight?
3 | Within the past 24 months, have you used by any means (including electronic vaporizer or “vaping”), a substance or
product containing tobacco, nicotine or marijuana?
If YES, smoker rates applicable.
Canada Protection Plan™ | Application for Life Insurance
MAY BE
SUBJECT TO
UNDERWRITING
SUBJECT TO
UNDERWRITING
Application for Life Insurance
The plan you may be eligible
for will be determined by our
underwriting department.
Details
Optional Riders Amount
Permanent Insurance Plan Premium Payment Period Amount of Insurance
Term Insurance Plan Term Period Amount of Insurance
3
2
1
Guaranteed Acceptance Life (Ages 18–75)
Deferred Life (Ages 18–80)
Deferred Elite Life (Ages 18–80)
Simplified Elite Life (Ages 18–80)
Preferred Life (Ages 18–80)
Preferred Elite Life (Ages 18–80)
10 Year Term
1
(Ages 18–70)
20 Year Term
1
(Ages 18–60)
25 Year Term
1
(Ages 18–55)
25 Year Decreasing Term
1
(Ages 18–60)
Accidental Death Benefit (Ages 18–65)
Child Term Benefit
2
(Ages 18–60)
Hospital Cash Benefit
3
(Ages 18–65)
Deferred Elite T100 (Ages 18–80)
Simplified Elite T100 (Ages 18–80)
Preferred T100 (Ages 18–80)
Preferred Elite T100 (Ages 18–80)
Deferred Elite Term
Simplified Elite Term
Preferred Term
Preferred Elite Term
10 Year
(Ages 18–70)
20 Year (Ages 18–60)
25 Year (Ages 18–55)
25 Year Decreasing (Ages 18–60)
$5,000
$25/day
$10,000
$50/day
$15,000
$100/day
Pay to Age 100
20 Pay
Not available for:
>> Guaranteed Acceptance Life
>> Deferred Life
Pay to Age 100
Maximum two term
insurance riders
>> Riders can only be added if base
is longer than rider term period
(not equal).
>> Term insurance riders are not
available with Guaranteed
Acceptance Life, Deferred Life or
any 20 Pay plans.
Complete Child Term
Benefit questions on page 5
Not available with:
>> Guaranteed Acceptance Life
>> Deferred Life
Not available with:
>> Guaranteed Acceptance Life
>> Deferred Life
>> Deferred Elite Life
>> Deferred Elite Term
$
$
$
$
$
$
$
$
Coverage Details 04
Details
Preferred Plans
Minimum $50,000
Maximum $1,000,000
E
The plan you may be eligible
for will be determined by our
underwriting department.
Preferred Elite Plans
Minimum $500,000
Maximum $1,000,000
F
lbs
Imperial /ft’in”
kg
Metric /cm
Annual Monthly (PAD)
CREDIT CARD PAYMENT DETAILS Complete this section ONLY if paying ANNUALLY by credit card.
Card Number
Card Type:
VISA MASTERCARD
105941 (06/20) | 5
1
2
3
Cheque. Payable to Foresters Life Insurance Company; annual payment only.
Pre-Authorized Debit (PAD). Monthly payment only; complete PAD Plan Agreement on page 6.
Credit Card. Annual payment only; complete Credit Card Payment Details below.
For monthly (PAD) payment
method, there is no premium
debit for the first month.
For annual payment method, unless the
payor authorizes Foresters Life Insurance
Company (the Insurer) to withdraw the
initial premium by credit card, this
application must be accompanied by a
current dated cheque for the initial
premium due, payable to Foresters Life
Insurance Company. Annualized premium
is less for annual payment method.
Any special requests, including
premium and issue instructions,
may be added here.
Cheque
Credit Card
Premium for the frequency
$
Premium payment frequency
Premium payment method
Payment method for initial premium for annual payment, if dierent than payment method indicated above.
Initial premium for payment must be provided with this Application if annual payment method is chosen.
Is a third party involved with this application for insurance, or will a third party have the use of, or
access to, the cash value of the policy?
If YES, complete a separate Third Party Determination form CP011 for each third party.
Yes No
Application for Life Insurance
Canada Protection Plan™ | Application for Life Insurance
Premium Details06
Special Requests / Details07
A third party is an individual or
entity with an interest in a policy,
but is not the Insured, Owner,
Payor or trustee for a minor
beneficiary. Examples include
power of attorney and executor.
Third Party Determination08
Identify each child of the
Insured under 18 years of age.
Male Female
Child Name
Date of Birth
(MM/DD/YY)
Age (Yrs) Sex
ELIGIBILITY QUESTIONS
PAYMENT PLAN
Child Name Child NameChild Name
1 | Has any child named above ever received medical care, surgical care, or prescribed medications or been investigated for or
diagnosed with: cancer, leukemia, aplastic anemia, congenital or hereditary cardiac or neurological disease, bronchopulmonary
dysplasia, cystic fibrosis, chronic kidney disease, Werdnig-Homann disease (Infantile Spinal Muscular Atrophy), muscular
dystrophy, chronic hepatitis, HIV positive, developmental problems, diabetes or autism?
Yes No
Yes No
2 | Has any child named above ever been referred by a physician for a specialist’s consultation, been advised to have
treatment or been advised to have a diagnostic test, any of which have not yet been completed?
If you answered YES to any of the questions for any child named above, please indicate the child's name below. The child named is excluded from the Child Term Benefit.
Child Term Benefit05
Male Female
Male Female
Male Female
MONTHLY
ANNUAL
Cardholder name as it appears on the card
Expiry Date
Signature
click to sign
signature
click to edit
Personal related Business related
105941 (06/20) | 6
MM / DD / YY
MM / DD / YY
Signature of Account Holder
Signature of Joint Account Holder
(if applicable)
Date
Date
Canada Protection Plan™ | Application for Life Insurance
Chequing Savings
Attached VOID cheque Banking information below
(complete if cheque is not attached)
Monthly Withdrawals under this PAD Agreement are:
PAD PLAN AGREEMENT
PAD bank account information to be taken from:
Street Address City/Town Province/Territory Postal Code
Pre-Authorized Debit (PAD) Plan Agreement 09
NOTE: Each premium for
coverage applied for in this
Application (if not paid with
this Application), will be
drawn from the account
identified on the attached
VOID cheque, or account
information provided, unless
otherwise instructed.
Application for Life Insurance
Type of Account Transit # (5 digits) Account #
Name of Financial InstitutionFinancial Institution #
(3 digits)
Address of Financial Institution
The payor, by signing below, verifies that the payor is an account holder of the account identified above or on the
attached VOID cheque and agrees that:
The Insurer is authorized to make deductions monthly under this Agreement from that account or another
account later identified or substituted by the payor for premium and insurance charges for each Policy issued by
that Insurer in response to this Application.
The financial institution from which the deductions are to be made is authorized to treat each deduction by the
Insurer as though the payor made it personally.
The Insurer reserves the right to determine when the first deduction, if any, will be made and the amount of that
deduction for each Policy issued by it; the subsequent deduction amounts may be variable.
This Agreement is eective immediately and will continue until terminated, which either the payor or the Insurer
may do at any time by providing notice of at least 30 days to the other. Payor may obtain a sample cancellation
form or further information on the right to cancel a PAD Plan Agreement at his/her financial institution or by
visiting www.payments.ca.
Should funds not be available due to insucient funds, the Insurer may, at its option, draw from the payor’s
account on the next scheduled withdrawal date for the insu
cient amount applicable to each Policy while that
Policy is in eect.
The payor has certain recourse rights if any debit does not comply with this Agreement. For example, the payor
has the right to receive reimbursement for any debit that is not authorized or is not consistent with this
Agreement. To obtain more information on recourse rights, the payor may contact his or her financial institution
or visit www.payments.ca.
If the payor is signing this Agreement electronically, the payor agrees that the time period for providing written
confirmation of this Agreement, before the first deduction, can be reduced from 15 days to 3 days. If handwriting
the signature, written confirmation is not required before the first deduction which can be made at any time.
The payor may contact the Insurer at its address and phone number:
Attention: Policyowner Services, Foresters, 250 Ferrand Drive, Suite 1100, Toronto, ON M3C 3G8
Phone Number: 1-877-629-9090
The payor waives the right to receive pre-notification of the amount and date of the first deduction and of a
change in the deduction amount required as premium or charges for each Policy in eect, or a change in amount
requested by the payor by whatever means.
The account holder must sign this PAD Plan Agreement as his/her name appears on bank records for the account provided.
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
If a Savings account is used, please
ensure it is eligible for pre-authorized
payments.
See the Application Checklist (on the
inside cover page) for a sample cheque
that shows location of transit #, financial
institution # and account #.
SAVINGS ACCOUNT
SAMPLE CHEQUE
Withdrawal date requested (1
st
28
th
)
click to sign
signature
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signature
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105941 (06/20) | 7
Agreements and Authorizations10
Application for Life Insurance
Canada Protection Plan™ | Application for Life Insurance
DEFINITIONS
AGREEMENT
These definitions apply for
purposes of this Agreement
and Authorization.
AUTHORIZATION
A photocopy of this
authorization shall be as valid
as the original.
SIGNATURES
This Application must be
current dated and received
at Canada Protection Plan's
Head Office within 14 days
of signature date.
OTHER PRODUCTS
AND SERVICES
I, by signing this Application, agree that:
The statements and answers contained in this Application, and other evidence of insurability signed or provided by
me, are true and complete and will be relied upon by the Insurer in deciding whether to issue a Policy.
For the purpose of determining eligibility for insurance, the Insurer may consider risk characteristics other than those
mentioned in the questions in this Application.
A Policy issued, if any, by the Insurer will only come into eect according to the terms of that Policy, which may include
factors such as the date this Application was approved, the Policy issue date, payment of the first premium, and
provided there is no change in insurability, as described in the Policy, prior to the date of delivery of the Policy.
The Insurer may void the Policy in the event of any misrepresentation by me in this Application or in any other
documents or answers delivered to the Insurer in connection with this Application.
No advisor, medical examiner or any other person has authority to advise that any untrue or incomplete answer or
information is acceptable and has no power, except for Foresters Life Insurance Company’s President or Corporate
Secretary, or successor positions, to make, modify, or discharge a Policy.
I expressly agree to have this Application, the Policy and any related documents in English. Je demande expressément
que ce document ainsi que tous les documents y aérents soient rédigés en anglais.
The Insured has received a copy of the Important Notices page.
Changes or corrections made to this Application, if any, by the Insurer are ratified by the Owner if the Policy delivered
to the Owner is not returned to the Insurer during the cancellation period.
If I have chosen to provide a current internet email address or other electronic contact information in this Application
or choose to provide such address or contact information in the future, the Insurer may use that address or contact
information to send messages, information or documents to me electronically relating, directly or indirectly, to this
Application and the Policy, or to membership, events, benefits, claims, administration or other goods and services.
I understand and agree that my signature below applies to, and is for the purposes of, this entire Application.
I, by signing this Application, authorize, on my own behalf and on behalf of each Child, the collection and use of
information about us, by an Authorized Person for an Authorized Purpose, from any: physician, medical practitioner,
hospital, clinic, or medical facility; employer; benefit plan, other insurer or institution; public records; or MIB, Inc.
I, by signing this Application, authorize, on my own behalf and on behalf of each Child, an Authorized Person to make a
brief report about my and each Child’s personal health information to MIB Inc., even if this Application is cancelled or
withdrawn. Information may be disclosed: between and among Authorized Persons; to companies that I have applied
or may apply to for life or health insurance, or benefits; as required or permitted by law.
Each person providing this authorization may, by written notice to the Insurer, revoke their authorization. Revoking
authorization, however, will not aect action(s) begun before receipt of notice or prevent an Authorized Person from
using personal information to administer a Policy, report to MIB Inc. if previously authorized to do so, or to inform of or
administer the benefits of membership.
By checking this box, I consent to receiving written or electronic messages from Canada Protection Plan with
information about other products and services that may be of interest to me. I may withdraw my consent at any time.
“Application“ means this Canada Protection Plan Application for Life Insurance. “Insured“ and “Owner“ mean each
person identified as such in this Application. “I/me” means individually each person identified in this Application as
either the Insured or the Owner. “Insurer“ means Foresters Life Insurance Company. “Policy“ means a policy issued by
the Insurer in response to this Application and includes each rider that is attached to it. “Authorized Purpose“ means:
assessing, servicing or administering insurance coverage, a Policy, claim or the benefits of membership; identity
verification, auditing, products and services; any other purpose as required or permitted by law. “Authorized Person“
means the Insurer, reinsurer, advisor, insurance agency, managing general agency and market intermediary related to
this Application or a Policy and the respective parent, aliates and authorized representatives of each and those
performing services on behalf of one or more of the preceding in relation to an Authorized Purpose, this Application,
or a Policy, benefit claim, membership or management of the respective business of each. “Child“ means each child
identified in the Child Term Benefit section of this Application.
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
Signature of Owner
(only if dierent)
Signature of witness
to all signatures
Advisor’s Name
Signature of Insured
Dated at this day of , 20
Province/Territory
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signature
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signature
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signature
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105941 (06/20) | 8
MM / DD / YY
MM / DD / YY
Signature of Advisor
Signature of training supervisor where required
Date
MM / DD / YY
Signature of servicing agent if dierent from above Date
Date
1 | How long have you known the Insured?
3 | Who initiated this application?
4 | Did you meet with the Owner and Insured in person to complete this application?
5 | Did you verify the identity of the Owner, by confirming that the identification details provided in this application match
original identification documents shown to you?
7 | Do you know of any information not disclosed in this application that may be important to assessing the
insured’s eligibility for the plan applied for?
If YES, please provide details:
6 | Was a needs analysis done?
2 | Are you related to the Insured?
If YES, what is the nature of your relationship?
If NO, please indicate method for obtaining the answer to the questions in this application:
Name of paramedical provider Order Number
Yes No
Yes No
Yes No
Yes No
Yes No
Telephone and/or mail Video conference / Skype
Owner Insured
Advisor Name
(first, middle, last) Advisor Code Agency Code Split %
Canada Protection Plan™ | Advisor's Report
Advisor's Report
ADVISOR
INFORMATION
RELATIONSHIP
TO INSURED
AND DISCLOSURE
When shown original
identification documents to
verify identity, you must
confirm that the documents
are valid, original and
unaltered by reviewing both
sides of each document.
REQUIREMENTS
ORDERED
SIGNATURE OF
ADVISOR WHO
COMPLETED THIS
APPLICATION AND
ADVISOR’S REPORT
Preferred Plans and
Preferred Elite Plans ONLY
I provided to the Insured and the Owner the Important Notices page and a statement of disclosure outlining the
companies I represent, the fact that I receive compensation for the sale of life and health insurance company
products, and that I may receive additional compensation in the form of bonuses, conference programs or other
incentives. I have also disclosed any conflicts or potential conflicts of interest with respect to this transaction.
To the best of my knowledge and belief, the information provided in the application is current, correct and
complete. I am not aware of any additional information that is material to the underwriting and acceptance of this
application that has not been disclosed in this application or Advisor’s report.
Reasonable eort was exercised by me to determine if the Owner is acting on behalf of a third party.
If I suspect that an undisclosed third party is involved, I will immediately email details to compliance@cpp.ca.
I have reviewed this application and Advisor’s report.
Advisor
Blood Chemistry Profile
Paramedical Exam
Other (specify)
Foresters Life Insurance Company acknowledges the receipt of $ to be applied in payment of the first premium for
insurance on the life of
Insurance coverage commences on the date the application is approved subject to the initial premium being honoured when first presented for
payment to the financial institution from which payment is to be made.
If the policy is not received within six (6) weeks of the date of this receipt, please contact Canada Protection Plan at the address on the back cover.
The Owner has the right to cancel the Policy issued and receive a full refund of premium paid for it by notifying the Insurer in writing and returning
the policy within 10 days of first receiving it.
City / Province
Dated at this day of , 20
Important Notices
NOTICE REGARDING MIB
Respecting your privacy is important to us at Canada Protection Plan and Foresters Life Insurance Company. We will maintain your Personal
membership. Information in your file will be collected, used and disclosed, on a continuing basis, by Canada Protection Plan and Foresters, our
employees, reinsurers, agents and representatives, service providers or professional consultants to determine your eligibility for our products and
services; to assess or administer claims; to administer your policy and address your questions; to tell you about, and provide, the benefits of
membership; provide you with information about products, services or member benefits that may meet your needs; to help us continually improve
our services and develop programs for our members; and as further described in the Authorization section of the application. We will restrict access
for us and to any person or organization to whom you gave consent. Our employees, service providers, representatives, reinsurers and any of their
service providers may be located outside Canada. As such, your Personal Information may be subject to the laws of other jurisdictions and may be
disclosed in response to demands or requests from government authorities, courts, or law enforcement in those countries. You are entitled to access
your Personal Information contained in your file and, when applicable, to have it corrected. You may also ask us not to send you information about
our products, services, or member benefits. To do either of these, please write to: Canada Protection Plan at 250 Ferrand Drive, Suite 1100,
Toronto, Ontario M3C 3G8. To access our most recent privacy policies, please visit our websites at www.cpp.ca and www.foresters.com.
Information regarding your insurability will be treated as confidential. We, or our reinsurers may, however, make a brief report on it to MIB Inc.,
formerly known as Medical Information Bureau, a non-profit membership organization of life insurance companies, which operates an information
exchange on behalf of its members. If you apply to another MIB member company for life, disability or health insurance coverage, or a claim for
benefits is submitted to such a company, MIB, upon request, will supply that company with the information about you in its file. If you question the
MIB, 330 University Avenue, Toronto, Ontario M5G 1R7. Its telephone number is (416) 597-0590 and website is www.mib.com.
POLICY LIMITATIONS
In the case of suicide, while sane or insane, within two years from the issue date of the policy, the benefit is limited to a refund of premiums paid.
For Guaranteed Acceptance Life, if death occurs within two years from the policy issue date and is due to non-accidental causes
(other than suicide), the death benefit will be equal to the premiums paid.
For Deferred Life, if death occurs within two years from the policy issue date and is due to non-accidental causes (other than suicide),
the death benefit will be equal to the premiums paid plus 3% interest.
For Deferred Elite Life and Deferred Elite Term, if death occurs within two years from the policy issue date and is due to non-accidental causes
(other than suicide), the death benefit will be equal, in the first year, to the premiums paid plus 3% interest and, in the second year, to 50% of the
face amount.
For Accidental Death Benefit, the benefit payable may be limited by factors such as the Insured’s age and the cause of death. Please see your
policy for detailed terms and conditions.
The policy that may be issued as a result of this application has important terms and limitations. You should review it carefully as soon as you receive it.
R E CEIPT
(Detach and present to Owner ONLY if a cheque was provided for payment of the first annual premium.)
105941 (06/20)
(Detach and present to Insured)
Distributed by
Canada Protection Plan
Thank you for placing your trust in Canada Protection Plan,
providing you with peace of mind.
Along with reliable support and compassionate service, there are many other advantages to apply:
As a policyholder, you may be eligible to enjoy a valuable package of complimentary benefits.*
When you receive your policy, all complimentary benefits will be outlined. The following are just a few of these benefits:
* Some of the benefits listed are available, at no charge, to eligible Foresters policyholders with an insurance plan of $10,000 or more; they are oered to the insured under a policy,
are non-contractual, subject to benefit specific eligibility requirements, definitions and limitations and may be changed or cancelled without notice.
**
Not available in Quebec, the Territories and Nunavut.
We stand by you today, so your loved ones are protected for tomorrow.
Payments start in the second month - applicable on monthly payment plans only
You can apply for coverage up to $500,000 on many No Medical plans
You can apply for coverage up to $1 million on all Preferred Plans
If you are ages 18 to 80, you can apply
Most of our term plans are renewable and convertible
Low rates in comparison to similar plans and benefits
Canada Protection Plan is underwritten by Foresters Life Insurance Company of Canada, which is a member of
Assuris and a subsidiary of Foresters (established in 1874).
Online document
preparation service** for customizable wills, powers of attorney and healthcare directives
Emergency assistance program providing short term financial assistance
Orphan benefits of up to $900 monthly per child up to age 18
Everyday money toll free financial help line providing counselling
Competitive Scholarship program can provide up to $8,000 over 4 years for postsecondary education
Foresters Community Grants providing additional funding to your community projects
Transportation benefit providing up to an additional $2,000 to return the deceased back home
250 Ferrand Drive, Suite 1100
Toronto, Ontario
M3C 3G8
www.cpp.ca
Tel: (416) 447–6060
Toll free: 1–877–447–6060
Fax: (416) 447–9881
CANADA PROTECTION PLAN and the logo are trademarks of Canada Protection Plan Inc. Used under licence.
Underwritten by
Foresters Life Insurance Company
Foresters Financial and Foresters are trade names and trademarks of The Independent Order of Foresters
(a fraternal benefit society, 789 Don Mills Road, Toronto, Ontario, Canada M3C 1T9) and its subsidiaries, including Foresters Life Insurance Company.
APP_LifeInsurance_BRKR_E_0620
105941 (06
/20)
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Completed 16 November 2020

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