REINSTATEMENT/CHANGE 07/2017
Application for
REINSTATEMENT and/or CHANGE
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APPLICATION FOR REINSTATEMENT AND/OR CHANGE
REINSTATEMENT/CHANGE 07/2017 Page 1 of 13
A. POLICY IDENTIFICATION complete in all cases (print)
POLICY NO.
1. Life Insured Policy Owner
Name
Last First Middle
Address
Phone Numbers: Home
Business
Occupation
Employer’s Name
2. Second Insured Policy Owner Joint Policy Owner
Name
Last First Middle
Business Name
Address
Phone Numbers: Home
Business
Occupation
Employer’s Name
DECLARATION OF TAX RESIDENCE (only required for Conversion to permanent cash value product plan change)
3. (a) U.S. CITIZEN OR RESIDENT
Individual(s):
Policy Owner
Joint Policy Owner
(if applicable)
Are you a U.S. citizen or a U.S. resident for U.S. tax purposes? Yes No Yes No
If ‘Yes’, provide your U.S. Taxpayer Identification Number (TIN):
Entities:
Please complete the Declaration of Tax Residence for Entities form available on the Broker Forms page of our website.
(b) RESIDENT OF A COUNTRY OTHER THAN CANADA OR THE U.S.
Individual(s):
Policy Owner Joint Policy Owner
(if applicable)
Are you a tax resident of a jurisdiction other than Canada or the U.S.? Yes No Yes No
If ‘Yes’, give your jurisdictions of tax residence and taxpayer identification numbers (TIN).
If you do not have a TIN for a specific jurisdiction, give the reason using one of these choices:
Reason 1: I will apply or have applied for a TIN but have not yet received it.
Reason 2: My jurisdiction of tax residence does not issue TINs to its residents.
Reason 3: Other reason.
Jurisdiction of tax residence Taxpayer identification number
If you do not have a TIN, choose
reason 1, 2 or 3
Policy Owner
Joint Policy Owner
If reason 3 is selected, please specify:
Entities:
Please complete the Declaration of Tax Residence for Entities form available on the Broker Forms page of our website.
Canadian financial institutions are required under Part XVIII and Part XIX of the Income Tax Act to collect the information you provide on this
form to determine if we have to report your financial account to the Canada Revenue Agency (CRA). The CRA may share this information with
the government of a foreign jurisdiction that a person identified on this form is a resident of for tax purposes. In the case of the United States,
the CRA may also share the information with the U.S. government if the person is a U.S. citizen.
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REINSTATEMENT/CHANGE 07/2017 Page 2 of 13
B. DESCRIPTION (check all that apply)
EFFECTIVE DATE OF CHANGE
Reinstatement
Note: To reinstate Instant
Issue policy, Final Expense
policy or Quick Issue Critical
Illness policy, complete an
application for that plan.
If within 180 days of first overdue premium, complete Quick Application for Reinstatement.
If past 180 days of first overdue premium:
Complete Sections C, D, G and H.
For premiums paid via pre-authorized debit, also complete Section F.
Order age and volume underwriting requirements.
Full Conversion or
New Plan: __________________________________
Full Exchange
Note: Term exchange is only
available within 5 years from
the original issue date.
Complete Sections G and H.
If premiums paid via pre-authorized debit, also complete Section F.
If conversion, also complete Declaration of Tax Residence on Page 1.
Reissue Second Life Rider at current rates? Yes No
If Yes, please complete either the Full Application for Life Insurance or the Quick Life Application.
Partial Conversion and/or
New Plan: ______________________________ Amount to be converted: $_____________________
Partial Exchange
New Plan: ______________________________ Amount to be exchanged: $_____________________
Note: Term exchange is only
available within 5 years from
the original issue date.
If conversion, also complete Declaration of Tax Residence on Page 1.
Balance:
left at original rates? (new band rate may apply)
Complete Sections G and H.
If premiums paid via pre-authorized debit, also complete Section F.
or reissued as Term Rider?
Complete either the Full Application for Life Insurance or the Quick Life Application.
If premiums paid via pre-authorized debit, also complete Section F.
or cancelled?
Critical Illness Plan
Change
New Plan: ______________________________ Amount: $_____________________
Balance:
Note: Critical Illness plan
change is only available on
10-Year Term to Age 75 plans
issued May 2002 or later.
cancelled?
Complete Sections G and H
If premiums paid via pre-authorized debit, also complete Section F.
Complete Declaration of Tax Residence on Page 1.
Add Rider(s)/Benefit(s) Accidental Death or Disability Waiver
Complete Sections C, D, G and H
If premium paid via pre-authorized debit, also complete Section F.
Child Protection Rider Volume: $____________________
Complete Sections C on the Life Insured
Complete Sections C (questions 1, 2 & 3) and D on the child
Complete Sections G and H
If premium paid via pre-authorized debit, also complete Section F.
Note: Term Riders, Second Life Riders, and Joint Life Riders cannot be added using the Application for
Reinstatement and/or Change. Please complete either the Full Application for Life Insurance or the
Quick Life Application.
Delete Rider(s)/Benefit(s)
Describe:
Complete Sections G and H.
Apply for Non-Smoker
Rates
Complete Sections C, G and H.
If total coverage is $250,000 or more, a Urinalysis is required.
Note: Insured must not have used tobacco products in the previous 12 months (including cigarettes,
cigarillos, colts, cigars, pipes, chewing tobacco, snuff, e-cigarettes, nicotine gum or patches, or any form of
nicotine substitute) and must not have had any significant changes in insurability.
Reconsider Rating
Describe:
Complete Sections C, D, G and H.
Other
Describe:
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REINSTATEMENT/CHANGE 07/2017 Page 3 of 13
C. PERSONAL INFORMATION
1. For all individuals to be insured, show total life and critical illness insurance in force with this and other companies:
Name of Insured Name of Company Issue Year Purpose of Insurance Amount AD Amount
2. NAME D.O.B BIRTHPLACE
(only for CPR)
HEIGHT WEIGHT FULL NAME & ADDRESS OF
PERSONAL PHYSICIAN
DATE & REASON LAST
CONSULTED
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REINSTATEMENT/CHANGE 07/2017 Page 4 of 13
FOR ALL QUESTIONS ANSWERED ‘YES’, PROVIDE DETAILS IN QUESTION 12.
Life
Insured
YES NO
Other
Life
YES NO
3. Has any individual to be insured:
(a) Applied for any life, disability or critical illness insurance within the last 12 months, or is any other
application pending or contemplated?
(b) Ever had any insurance company rate, decline, modify or postpone any application for or reinstatement of
life, disability or critical illness insurance?
4. Has any individual to be insured:
(a) Any intention of changing duties or occupation? If “Yes”, provide details of new duties/occupation in
question 12.
(b) Any plans to change country of residence or to travel outside of North America within the next 24 months?
If so, please indicate location, purpose and intended length of stay.
(c) Flown within the last two years, or any intention of flying, other than as a passenger on commercially
scheduled airlines? If ‘YES’, complete Aviation Questionnaire.
(d) Within the last two years, participated in any hazardous activities such as motor vehicle racing, parachute
jumping, scuba diving, hang gliding, mountain/rock climbing, or is such activity contemplated? If ‘YES’,
complete appropriate questionnaire.
5. Has any individual to be insured used any tobacco or nicotine products including cigarettes, cigarillos, colts,
cigars, pipes, chewing tobacco, snuff, e-cigarettes, nicotine gum or patches, or any form of nicotine substitute?
If ‘YES’, which one of the following applies:
Life
Insured
YES NO
Other
Life
YES NO
LIFE INSURED OTHER LIFE
currently smoke daily less than 20 a day currently smoke daily less than 20 a day
currently smoke daily more than 20 a day currently smoke daily more than 20 a day
currently smoke occasionally (weekly, monthly, rare) currently smoke occasionally (weekly, monthly, rare)
quit less than a year ago quit less than a year ago
has not smoked/used the above products in the last 12 months has not smoked/used the above products in the last 12 months
If ‘YES’, how much? TYPE AMOUNT
In the last 12 months?
In the last 2 years?
In the last 5 years?
Are you a former smoker who has not smoked/used the above products in the last 12 months? If ‘Yes’, please
provide the reason for quitting and if you have been advised to quit by your doctor in question 12.
6. (a) Does any individual to be insured presently consume alcoholic beverages?
If ‘YES’, please complete the following:
BEER WINE LIQUOR Check one:
QUANTITY:
DAILY/WEEKLY/MONTHLY
(b) Did you ever drink more than you do at the present? If "Yes", indicate the time frame, the amount and the
reason for quitting or reducing your consumption in question 12.
7. Is any individual to be insured now using or has ever used the following drugs:
Heroin, morphine, Demerol, methadone, Amytal, Phenobarbital, Seconal, Nembutal, Pentobarbital, hashish,
cannabis, Benzadrine, Dexedrine, Methedrine, Cocaine, LSD, DMT, Mescaline, Peyote, Psilocybin, Anabolic
Steroids?
If ‘YES’, please give details: TYPE QUANTITY &
METHOD OF
CONSUMPTION
FREQUENCY OF
USE
DATES (from – to)
8. (a) Has any individual to be insured ever received treatment or been advised to seek treatment or medical
advice because of alcohol or drug usage? If ‘YES’, provide date, name and address of any doctor, hospital
or treatment center in question 12.
(b) Please add any additional information which you feel is important in question 12.
9. Has any individual to be insured ever been convicted of a criminal offense or are any charges pending?
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REINSTATEMENT/CHANGE 07/2017 Page 5 of 13
10. Driving History - Has any individual had:
(a) more than 2 driving violations in the past 3 years? If ‘YES’, please provide details including dates and types
of violations in questions 12.
(b) a license suspension, DUI (driving under the influence) or reckless driving violations in the past 5 years?
If ‘YES’, please provide details including dates and types of ALL violations in question 12.
(c) more than one DUI (driving under the influence) conviction in the past 20 years? If ‘YES’, please provide
details including dates and types of ALL violations in question 12.
(d) Do you have a valid Driver’s License? If ‘NO’, provide details in question 12.
(e) Does individual to be insured have a valid Driver’s License? If ‘NO’, provide details in question 12. If ‘YES’
provide: Life Insured: Doc. # __________________________ Jurisdiction______________________
2
nd
Life: Doc. # __________________________ Jurisdiction______________________
11. Since the policy was originally applied for, has any individual to be insured:
(a) had any illness, disease, operation or injury?
(b) consulted or been attended by a physician or other practitioner?
(c) have any reason to believe he/she is not in good health?
12. USE THE FOLLOWING SECTION FOR DETAILS TO ‘YES’ ANSWERS IN SECTION C.
Question # Name of Insured Details
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REINSTATEMENT/CHANGE 07/2017 Page 6 of 13
D. MEDICAL INFORMATION – To be answered by each individual to be covered.
FOR ALL QUESTIONS ANSWERED ‘YES’, CIRCLE THE APPROPRIATE DISORDER AND PROVIDE DETAILS IN QUESTION 18.
13. (a) Have any of your biological parents, brothers or sisters, whether living or deceased, had any of the
following?
LIFE
INSURED
YES NO
OTHER
LIFE
YES NO
heart disease
stroke
cancer or any other tumor
diabetes
polycystic, or other kidney
disease
Huntington’s Chorea
motor neuron disease
(including ALS/Lou Gehrig’s
Disease)
Alzheimer’s Disease
Parkinson’s Disease or
any other hereditary
disease
(b) Please complete the following chart for ALL family members:
Life Insured
DISEASE
AGE AT
DIAGNOSIS
ACTUAL
AGE, if
living
CONDITION, if alive
AGE
AT
DEATH
CAUSE OF DEATH
FATHER
MOTHER
BROTHER (1)
BROTHER (2)
SISTER (1)
SISTER (2)
Other Life
DISEASE
AGE AT
DIAGNOSIS
ACTUAL
AGE, if
living
CONDITION, if alive
AGE
AT
DEATH
CAUSE OF DEATH
FATHER
MOTHER
BROTHER (1)
BROTHER (2)
SISTER (1)
SISTER (2)
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REINSTATEMENT/CHANGE 07/2017 Page 7 of 13
FOR ALL QUESTIONS ANSWERED ‘YES’, CIRCLE THE APPROPRIATE DISORDER AND PROVIDE DETAILS IN QUESTION 18.
14. Has the individual to be insured ever been treated for, been advised to seek advice or treatment for or
had any known indication of, or any disorder of:
LIFE
INSURED
YES NO
OTHER
LIFE
YES NO
a) THE EARS, EYES, NOSE, THROAT, LUNGS including:
sleep apnea
sarcoidosis
cystic fibrosis
shortness of breath
persistent cough
coughing up blood
asthma
bronchitis
COPD
optic neuritis
any other eye, ear, nose,
throat, or lung disorder
If ‘YES’ to bronchitis or asthma, please complete Bronchitis or Asthma Questionnaire.
(b) THE HEART, ARTERIES OR OTHER PARTS OF THE CARDIOVASCULAR SYSTEM including:
angina
chest pain
elevated cholesterol
palpitation
irregular pulse
aneurysm
high blood pressure
rheumatic fever
heart murmur
heart attack
bypass or angioplasty
pacemaker
peripheral vascular disease
abnormal EKG
any other disease or
disorder of the heart or
blood vessels
(c) THE ABDOMINAL ORGANS including:
ulcer
hernia
ulcerative colitis
rectal bleeding or
blood in stool
Crohn’s disease
hepatitis
jaundice
liver disease
cirrhosis
chronic diarrhea
pancreatitis
colon polyps
any other disease or
disorder of the bowel,
stomach, pancreas or liver
(d) THE KIDNEYS, BLADDER and REPRODUCTIVE ORGANS including:
nephritis
blood, pus, sugar or protein in urine
kidney stones
breast disorder or unusual discharge
abnormal mammogram or breast ultrasound
abnormal PAP
elevated PSA (prostate specific antigen)
any other disease or disorder of kidneys,
bladder or reproductive organs
(e) THE BRAIN AND NERVOUS SYSTEM including:
epilepsy
seizures
stroke
transient ischemic attack
(TIA)
multiple sclerosis
numbness or tingling of limbs
impairment of speech
impairment of balance
memory impairment
cognitive impairment
fainting spells
paralysis
dementia
Alzheimer’s disease
Parkinson’s disease
motor neuron disease
(including ALS/Lou
Gehrig’s disease)
coma
head injury
persistent headaches
any other disease of the
brain or nervous system
(f) MENTAL HEALTH including:
depression
anxiety
panic attacks
PTSD
bi-polar disorder
schizophrenia
developmental delay or disability
eating disorder
chronic fatigue
ADD or ADHD
attempted suicide or suicidal thoughts
any other emotional or psychiatric disorder
(g) THE BLOOD, GLANDS and ENDOCRINE SYSTEM including:
anemia
bleeding disorder
blood clot
diabetes
leukemia
night sweats
enlargement of lymph
nodes (glands)
unexplained infections
any other endocrine or
blood disease or disorder
(h) THE MUSCULO-SKELETAL SYSTEM including:
arthritis
rheumatoid arthritis
lupus
amputation
chronic pain
muscular dystrophy
any other disorder of the
muscles, bones or joints
(i) THE IMMUNE SYSTEM including:
acquired immune
deficiency syndrome
(AIDS)
AIDS related complex
(A.R.C.)
positive HIV test
any other immunological
disorder
(j) CANCER, GROWTH and SKIN DISORDERS including:
cancer
cyst, tumor, lump,
polyp or other growth
abnormal biopsy or
pathology result
mole or unusual skin lesion(s)
any other growth or
malignancy
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REINSTATEMENT/CHANGE 07/2017 Page 8 of 13
D. MEDICAL INFORMATION (continued)
15. Other than as disclosed in the answers above, has any individual to be insured:
(a) Consulted a doctor or medical practitioner within the last 5 years?
(b) Had an EKG, Blood Tests or other diagnostic test within the last 5 years?
(c) Been a patient in a hospital or other medical facility within the last 5 years?
(d) Currently awaiting test results or been advised to have any diagnostic test, hospitalization or surgery which
has not been completed?
(e) Ever been tested for exposure to the AIDS virus?
(f) Lost more than 10 pounds (4.53 kg) within the last year?
(g) Requested or received a pension, benefits, disability payment or settlement because of an injury or illness?
(h) Had any health symptoms or complaints for which a physician has NOT been consulted or treatment
received?
16. (a) Is any individual to be insured currently under any treatment or medication?
(b) Do you have any reason to believe you are not in good health?
For Females Only:
(c) Are you currently pregnant? If so, please provide your due date: _______________________________
(d) Is it a normal pregnancy to date?
17. Has there been any change in name in the last 5 years (marriage, etc.)? If ‘YES’, please provide previous
name(s) in question 18.
18. USE THE FOLLOWING SECTION FOR DETAILS TO ‘YES’ ANSWERS IN SECTION D.
QUESTION
NUMBER
PROPOSED
INSURED DETAILS AS TO DIAGNOSIS, DURATION AND RESULTS DATE
NAME AND ADDRESS OF
PHYSICIAN AND/OR
HOSPITAL
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REINSTATEMENT/CHANGE 07/2017 Page 9 of 13
E. UNIVERSAL LIFE QUESTIONNAIRE (For changes on existing Universal Life plans)
Section A – Basic Information
AMOUNT OF INSURANCE:
UL SCHEDULED PREMIUM $
$
(Premiums for riders and benefits should be listed on page 10)
Section B – Universal Life Illustration Assumptions – All factors are chosen by the applicant.
How the Wawanesa Life Universal Life policy works:
All premiums received, less any Premium Taxes, are deposited to the Daily Interest Account. An amount representing the Monthly
Cost of Insurance and Monthly Administration Fee is withdrawn from the Daily Interest Account every month. The balance may be
directed to any of the following Savings Options at your discretion:
UNIVERSAL LIFE – SAVINGS OPTIONS
ALLOCATION OF
SCHEDULED
PREMIUMS*
ASSUMED
INVESTMENT
RATES**
GUARANTEED
INTEREST
ACCOUNTS
DAILY INTEREST ACCOUNT
INVESTMENT ACCOUNT ACCUMULATOR:
When the balance reaches $250.00, an Investment Account for a
term of _________ years will be created.
INDEX-LINKED
OPTIONS
CANADIAN EQUITY INDEX-LINKED ACCOUNT
U.S. EQUITY INDEX-LINKED ACCOUNT
INTERNATIONAL EQUITY INDEX-LINKED ACCOUNT
CANADIAN BOND INDEX-LINKED ACCOUNT
* For any option chosen, the minimum percentage is 5%.
** As chosen by the applicant for illustration purposes only.
TOTAL
100%
NET ILLUSTRATION
INTEREST RATE
____________%
F. PAYMENT INFORMATION (Select one)
Monthly Pre-Authorized Debit (PAD)*
Semi-Annual PAD*
Annual PAD*
* Complete PAD section below.
Semi-Annual Billing
Annual Billing
Total Modal Premium $
plus sales tax, if applicable
Amount paid with this application $
PRE-AUTHORIZED DEBIT (PAD)
Use my current Wawanesa Life PAD under Policy #
or PAD #
or:
Establish a new PAD and use:
Details from initial premium cheque Details from VOID cheque (attached) Information provided below:
Account Owner Name(s)
Telephone
Account Owner Address (if different from policy owner)
Transit #
Fin. Inst. #
Account #
Branch Address
Withdrawal date: Policy date or ____ (1
st
– 28
th
)
Draw premium upon approval.
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REINSTATEMENT/CHANGE 07/2017 Page 10 of 13
G. AGREEMENT AND DECLARATION / AUTHORIZATION AND SIGNATURES
Each of the undersigned insureds and/or policy owners agree that:
1. All statements, agreements, representations and answers made in this Application, and any additional declarations or answers which may be
made in any personal declaration required in connection with this Application, together with all prior applications, shall be consideration for
the basis of the reinstatement and/or changed policy(ies) hereby requested.
2. The answers to the statements and questions are complete, true and correctly recorded.
3. In order to effect the change the Company shall have the right either (a) to cancel the present policy and make another policy containing
current terms corresponding to the terms of the changed policy, or (b) to amend the present policy.
4. Except as changed by this Application, any indebtedness under the policy and the rights of any beneficiary, assignee or other person having
an interest in the policy shall remain as unchanged.
5. Delivery to and acceptance by the policy owner of any policy issued in consequence of this Application will ratify any amendments to the
change of policy made by the Company.
6. The reinstatement and/or change shall not take effect until: (a) approved by the authorized officers of the Company, (b) all premiums and
fees required have been paid, and (c) the policy is delivered, no change having taken place in the insurability of the Life Insured, Second Life
Insured or Insured Children subsequent to the completion of this Application.
7. If, within two years from the date of approval of the reinstatement and/or change, the Life Insured or any other individuals proposed for
coverage dies by suicide, whether sane or insane, or if any information submitted in support of this Application is proved to be materially
incomplete or untrue, the reinstatement and/or change will be void.
AUTHORIZATION: THE FOLLOWING AUTHORIZATION IS VALID FOR EACH INDIVIDUAL FOR WHOM EVIDENCE OF
INSURABILITY IS REQUIRED.
I acknowledge having received the notices regarding Medical Information Bureau Inc. (MIB, Inc.) and Investigative Reports, and consent to
such reports being obtained by Wawanesa Life. I authorize Wawanesa Life, or its reinsurers, to make a brief report of my personal health
information to The Medical Information Bureau Inc. (MIB, Inc.).
I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company,
Medical Information Bureau Inc. (MIB, Inc.), Motor Vehicle Department concerning driver abstract, or other organization, institution or person
that has any records or knowledge of me or my health or of my children or their health to give Wawanesa Life or its reinsurer(s) any such
information.
I authorize Wawanesa Life to perform such tests, examinations, x-rays, electrocardiograms, urinalysis, general blood profiles including blood
tests for AIDS as may be required to medically underwrite this Application for insurance. I authorize the Medical Director of Wawanesa Life to
release all medically related information obtained during the underwriting process to my/our personal physician or other medical practitioner.
PRE-AUTHORIZED DEBIT (PAD) AUTHORIZATION (if applicable – please complete Section F on page 9)
I request and authorize Wawanesa Life to make withdrawals from the account designated on page 9 of this application or from any
subsequently designated account in order to make policy payments and/or specific payments on loan indebtedness, under the following terms:
1. Withdrawals will be made according to the payment frequency indicated on the application on the policy issue date unless a particular
withdrawal day is specified.
2. If a monthly PAD is returned as insufficient funds, the next PAD amount will be for the two months of premium. Notification will be provided
prior to this double withdrawal.
3. I may revoke my authorization at any time, subject to providing written notice of 10 days to Wawanesa Life. (For more information on your
right to cancel a PAD agreement, contact your financial institution or visit www.cdnpay.ca.)
4. I have certain recourse rights, provided under the personal PAD agreement, if any debit does not comply with the agreement. For example, I
have the right to receive reimbursement for any debit that is not authorized or is not consistent with the personal PAD agreement. (For more
information on your recourse rights, contact your financial institution or visit www.cdnpay.ca.)
5. I may provide written request to add/delete policies to the PAD agreement or change bank information without completing a new PAD
agreement.
I waive the right to receive 10 days’ notice of an increase or decrease in the amount of the automatic withdrawal due to premium
changes during the underwriting process. Notification of premium changes will be provided when the policy is issued.
POLICY BENEFITS DISCLOSURE STATEMENTS – UNIVERSAL LIFE PLANS ONLY
I acknowledge and understand that:
1. An illustration of the product applied for has been presented to me for review.
2. Investment returns for the purposes of the illustration have been chosen by me and are NOT GUARANTEED.
3. The account values and cash surrender values illustrated will change subject to fluctuation in future investment values.
Variations in these factors will also impact any illustration in which it is projected that premiums may be discontinued at some future time.
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REINSTATEMENT/CHANGE 07/2017 Page 11 of 13
G. AGREEMENT AND DECLARATION / AUTHORIZATION AND SIGNATURES (Continued)
CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION
I consent to Wawanesa Life collecting, using and disclosing my personal information for the purposes of: establishing and maintaining
communications with me; underwriting risks on a prudent basis; investigating and paying claims; receiving payments of insurance premiums
and policy loan repayments; withdrawing premiums from and depositing funds into my account (applicable if PAD Agreement is signed);
detecting and preventing fraud; offering and providing products and services to meet my needs; compiling statistics and acting as required or
authorized by law.
I have read and understood that Wawanesa Life may share my personal information with the required people, organizations and service
providers as described in the Notice of Consent & Disclosure Regarding Personal Information on Customer Copy, who may be in other
provinces or in jurisdictions outside Canada. My information may be shared as required by the laws of those jurisdictions.
I recognize that in providing services to me in the future and providing me with the benefits included in the policy I am applying for, Wawanesa
Life may need to collect, use and disclose additional personal information about me. I confirm that this consent applies to that personal
information as well.
I understand that any restriction or withdrawal of my consent may result in Wawanesa Life being unable to provide me with the product or
service being applied for or having to terminate the policy.
You can obtain further information about Wawanesa Life's Personal Information Protection Policy and practices concerning service providers
outside Canada from the Wawanesa Life Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at www.wawanesalife.com.
If you have a question (including a question concerning our collection of personal information, or the collection, use, disclosure or storage of
personal information by service providers outside Canada on our behalf) or complaint regarding our privacy policies or procedures, please
contact the individual accountable for our personal information protection compliance: Senior Vice President, Chief Legal Officer & Corporate
Secretary, The Wawanesa Life Insurance Company, 900-191 Broadway, Winnipeg, Manitoba R3C 3P1.
I confirm that I have read, understood and accepted the terms and conditions of the agreements, declarations and authorizations contained in
this application. I further confirm that all of my answers to the declarations are truthful and complete to the best of my information, knowledge
and belief. A photocopy or an electronic reproduction of this document will be as valid as the original.
Signed at _________________________ in the province of __________________________________________. Date __________________________________
___________________________________________
Life Insured, or parent if Life Insured is
under age 16
(please print)
___________________________________________
Second /Joint Life Insured (please print)
___________________________________________
Policy Owner, if other than Life Insured
(please print)
___________________________________________
Life Insured, or parent if Life Insured is
under age 16
(signature)
___________________________________________
Second/Joint Life Insured (signature)
___________________________________________
Policy Owner, if other than Life Insured
(signature)
___________________________________________
Child under Child Protection Rider, if
age 16 or older
(signature)
__________________________________________
Witness (signature)
__________________________________________
PAD Account Owner (signature)
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REINSTATEMENT/CHANGE 07/2017 Page 12 of 13
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Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.
H. STATEMENT BY INDEPENDENT INSURANCE BROKER
PREMIUM CALCULATIONS
BASIC PLAN
$____________________
TERM RIDER 1
$____________________
Modal Premium: Monthly
$
______________________
TERM RIDER 2
$____________________
TERM RIDER 3
$____________________
S.A.
$
______________________
TERM RIDER 4
$____________________
SECOND/JOINT LIFE INSURED RIDER 1
$____________________
Annual
$
______________________
SECOND/JOINT LIFE INSURED RIDER 2
$____________________
SECOND/JOINT LIFE INSURED RIDER 3
$____________________
Amount paid with Application
$
______________________
SECOND/JOINT LIFE INSURED RIDER 4
$____________________
CHILD PROTECTION RIDER
$____________________
DISABILITY WAIVER
$____________________
ACCIDENTAL DEATH
$____________________
OTHER:
_
_
_
______________________ $____________________
POLICY FEE
$____________________
TOTAL PREMIUM
$____________________
SALES TAX (if applicable)
$____________________
TOTAL AMOUNT
$____________________
1. Does any proposed insured have any obvious physical impairment or do you know anything about the insured that might affect the risk?
YES NO
2. If insurance is applied for on a minor child:
Have you seen the child?
YES NO
Does the child appear healthy?
YES NO
Do you know anything about the child that might affect the risk?
YES NO
Does the child reside with the parent/guardian?
YES NO
3. What evidence is being submitted or arranged? Paramed Xray Blood Urinalysis EKG HOS
Name of paramed facility or examiner: __________________________________________________________________
MVR to be ordered by (check one, if applicable): Branch Office Executive Office
4. Mail policy to: Policy Owner (direct delivery) or Independent Insurance Broker (personal delivery)
If no preference is indicated, policy will be mailed directly to policy owner.
5. Details of ‘YES’ answers and additional comments (‘NO’ answers to question 2).
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REINSTATEMENT/CHANGE 07/2017 Page 13 of 13
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Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.
INDEPENDENT INSURANCE BROKER’S DECLARATION
I declare that I have asked and fully recorded the answers of all lives proposed to all questions on this Application, and that I know of
nothing that is material to their insurability that has not been recorded herein. I am aware of and in compliance with the Company’s
Sales Code of Ethics.
Confirming Independent Insurance Broker Disclosure (purchase of insurance only)
I have provided the applicant(s) with written materials advising: about the company(s) I currently represent; that I receive compensation
(such as commissions or a salary) for the sale of life and health insurance products; that I may receive additional compensation in the
form of bonuses or other incentives; and of any conflicts of interest I may have with respect to this transaction.
_____________________________________________________ _________________________________________________________
SELLING BROKER (please print) SELLING BROKER (signature)
ALLOCATION OF THIS SALE
FIRST YEAR RENEWAL
_____________________________________________________ ____________________ _______% ______%
AGENT OF RECORD (please print) Broker Number
_____________________________________________________ ____________________ _______
% ______%
SERVICING AGENT (please print) Broker Number
_____________________________________________________ ____________________ _______
% ______%
OTHER (please print) Broker Number 100 100
THE WAWANESA LIFE INSURANCE COMPANY 400-200 MAIN STREET, WINNIPEG, MB R3C 1A8
PHONE 1-204-985-3940 TOLL FREE 1-800-263-6785 FAX 1-888-985-3872
®
REINSTATEMENT/CHANGE 07/2017
®
Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.
®
APPLICATION FOR REINSTATEMENT AND/OR CHANGE
REINSTATEMENT/CHANGE 07/2017 Customer Copy 1 of 2
NOTICES & DISCLOSURE STATEMENTS
CUSTOMER COPIES
NOTICE OF MEDICAL INFORMATION BUREAU, INC. (MIB, Inc.)
Information regarding your insurability will be treated as confidential. We, or our reinsurers may, however, make a brief report
thereon to the MIB, Inc., a non-profit membership organization of insurance companies which operates an information exchange
on behalf of its members. If you apply to another MIB, Inc. member company for life and health insurance coverage, or a claim for
benefits is submitted to such a company, MIB, Inc., upon request, will supply such company with the information it may have in its
file.
Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the
accuracy of information in MIB, Inc.’s file, you may contact MIB, Inc. and seek a correction in accordance with the procedures set
forth in the federal Fair Credit Reporting Act. The address of MIB, Inc.’s information office is 330 University Avenue, Suite 501,
Toronto, ON M5G 1R7, telephone number (416) 597-0590.
We, or our reinsurers, may also release information in our file to other life insurance companies to whom you may apply for life and
health insurance, or to whom a claim for benefits may be submitted.
NOTICE OF INVESTIGATIVE REPORTS
In the processing of the application for reinstatement/change, The Wawanesa Life Insurance Company may obtain Motor Vehicle
Driving abstract/records, a personal investigation or consumer reports containing personal information about the individuals
proposed for insurance.
NOTICE OF CONSENT TO RELEASE MEDICAL/UNDERWRITING INFORMATION
As part of the underwriting process, the Medical Director of Wawanesa may need to release medically related information obtained
during the underwriting process to your personal physician or other medical practitioner. We may also need to disclose information
regarding the underwriting factors to your Wawanesa Life independent insurance broker.
NOTICE OF CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION
We collect, use and disclose your personal information in order to administer the products and services you have requested.
Personal Information is collected for the purposes of: establishing and maintaining communications with you; underwriting risks on
a prudent basis; investigating and paying claims; receiving payments of insurance premiums and policy loan repayments;
withdrawing premiums from and depositing funds into your account (applicable if PAD Agreement is signed); detecting and
preventing fraud; offering and providing products and services to meet your needs; compiling statistics and acting as required or
authorized by law.
We may share your personal information with the following people, organizations and service providers: Wawanesa Life employees
and independent insurance brokers who require this information to perform their jobs; third party providers who require this
information to provide their services to you, which may include paramedical agencies, underwriters, claims investigators,
investigative agencies, providers of information processing and storage, programming, printing, mailing and distribution services;
applicable reinsurance companies to allow them to evaluate and administer any insurance risk that the accept; the Medical
Information Bureau Inc. (MIB, Inc.) as explained the notice provided; people to whom you have granted access; and people who
are legally authorized to view your personal information. These people, organizations and service providers may be in other
provinces or in jurisdictions outside Canada. Your information may be shared as required by the laws of those jurisdictions.
There are other situations where we may share aspects of your personal information with others, as described below:
We may share medical information collected about you with your doctor.
We may share your personal information with an organization or person from whom we are collecting information about you,
but only as required to obtain the information needed.
If laboratory tests performed on our behalf show that you have tested positive for infectious diseases such as HIV or
hepatitis, we may report this information to the appropriate public health authorities, as required.
Because the medical information you include in this application becomes part of the printed contract, in the case of a corporate or
joint policy, your medical information may be included in the policy contract issued to the policy owner(s) and any subsequent
owners.
In order to provide services to you in the future and provide you with the benefits included in the policy, Wawanesa Life may need
to collect, use and disclose additional personal information about you. We may not require you to provide consent at that time.
Any restriction or withdrawal of your consent may result in Wawanesa Life being unable to provide you with the product or service
being applied for or having to terminate the policy.
You can obtain further information about Wawanesa Life's Personal Information Protection Policy and practices concerning service
providers outside Canada from the Wawanesa Life Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at
www.wawanesalife.com.
If you have a question (including a question concerning our collection of personal information, or the collection, use, disclosure or
storage of personal information by service providers outside Canada on our behalf) or complaint regarding our privacy policies or
procedures, please contact the individual accountable for our personal information protection compliance: Senior Vice President,
Chief Legal Officer & Corporate Secretary, The Wawanesa Life Insurance Company, 900-191 Broadway, Winnipeg, Manitoba
R3C 3P1.
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REINSTATEMENT/CHANGE 07/2017 Customer Copy 2 of 2
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Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.
NOTICE OF CONSENT REGARDING PRE-AUTHORIZED DEBIT (PAD) AUTHORIZATION (if applicable)
You request and authorize Wawanesa Life to make withdrawals from the account designated on page 8 of this application or from
any subsequently designated account in order to make policy payments and/or specific payments on loan indebtedness, under the
following terms:
1. Withdrawals will be made according to the payment frequency indicated on the application on the policy issue date unless a
particular withdrawal day is specified.
2. If a monthly PAD is returned as insufficient funds, the next PAD amount will be for the two months of premium. Notification will be
provided prior to this double withdrawal.
3. You may revoke my authorization at any time, subject to providing written notice of 10 days to Wawanesa Life. (For more
information on your right to cancel a PAD agreement, contact your financial institution or visit www.cdnpay.ca.)
4. You have certain recourse rights, provided under the personal PAD agreement, if any debit does not comply with the agreement.
For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with the
personal PAD agreement. (For more information on your recourse rights, contact your financial institution or visit
www.cdnpay.ca.)
5. You may provide written request to add/delete policies to the PAD agreement or change bank information without completing a
new PAD agreement.
6. You waive the right to receive 10 days’ notice of an increase or decrease in the amount of the automatic withdrawal due
to premium changes during the underwriting process. Notification of premium changes will be provided when the policy
is issued.
POLICY BENEFITS DISCLOSURE STATEMENTS – UNIVERSAL LIFE PLANS ONLY
WAWANESA LIFE IS COMMITTED TO AN HONEST AND OPEN RELATIONSHIP WITH ITS CLIENTS. TO ACHIEVE THIS, WE
ASK THAT YOU READ THE FOLLOWING DISCLOSURE STATEMENTS. THEY CONTAIN THE KEY ELEMENTS OF THE
UNIVERSAL LIFE PLAN YOU HAVE CHOSEN AND OUR INDEPENDENT INSURANCE BROKER WANTS TO ENSURE THAT YOU
HAVE A COMPLETE UNDERSTANDING OF YOUR PLAN.
You acknowledge and understand that:
1. An illustration of the product applied for has been presented to you for review.
2. Investment returns for the purposes of the illustration have been chosen by you and are NOT GUARANTEED.
3. The account values and cash surrender values illustrated will change subject to fluctuation in future investment returns.
4. Variations in these factors will also impact any illustration in which it is projected that premiums may be discontinued at some
future time.
INDEPENDENT INSURANCE BROKER DISCLOSURE STATEMENT
The following disclosure notice must be completed by the independent insurance broker and provided to you, in writing prior to you
entering into this financial transaction. Please ask your independent insurance broker for further information or details.
1. I, ________________________________, am a licensed insurance broker in the province of _______________________________.
2. This transaction is between you and WAWANESA LIFE.
3. In soliciting this transaction, I am representing WAWANESA LIFE and
_______________________________________________.
(Name of Agency)
4. In the past 12 calendar months, the majority of the insurance or financial products that I have sold were issued by the
following companies:
______________________________________________________________________________________________________________.
5. I am committed to selling on the basis of needs.
6. Upon completion of this transaction, I will receive compensation from WAWANESA LIFE and may receive additional
compensation in the form of bonuses or other incentives.
7. The nature and extent of my relationship with WAWANESA LIFE is as an independent insurance broker.
8. I and WAWANESA LIFE are prohibited from requiring you to transact additional business with WAWANESA LIFE or any
other person or corporation as a condition of this transaction.
9. I declare the following conflicts of interest, if any
:
______________________________________________________________________
____________________________________________ ____________________________________________________________
DATE SIGNATURE OF INDEPENDENT INSURANCE BROKER
THE WAWANESA LIFE INSURANCE COMPANY 400-200 MAIN STREET, WINNIPEG, MB R3C 1A8
PHONE 1-204-985-3940 TOLL FREE 1-800-263-6785 FAX 1-888-985-3872
®
INDEPENDENT INSURANCE BROKER DISCLOSURE STATEMENT