8. Please check
TOBACCO STATUS (CHANGE TO NON-SMOKER)
Attach a duly completed and signed F3A (including the Tobacco Use and Declaration of Insurability sections) form for each applicable insured.
8.1 Change the tobacco status to non-smoker for the following insured(s):
8.2 Please select the applicable option.
8.3 Is it Joint Last to Die coverage?
8.4 Is the coverage:
8.5 For a universal life policy, I would like the following target premium:
9. Please check
NON-SMOKER BONUS (INCREASE IN COVERAGE)
Please refer to the wording of the policy for non-smoker bonus eligibility.
9.1 Grant the non-smoker bonus to the following insured(s):
Please refer to the wording of the policy for the percentage of increase of coverage granted.
Insured (last and first name)
1. __________________________________________ 2. __________________________________________ 3. __________________________________________
For a coverage that was issued with a smoker rate due to age (child under age 15):
Changes for children under age 15 when the original coverage was issued will all take effect using the attained age.
No transaction fees.
For an insured aged 15 or more at issue who stopped using tobacco: Choose the applicable transaction fee and attach a cheque to the request.
If 12 months or less since the coverage was issued: No fees (the change will take effect according to the insured’s age at issue and the original rate).
If between 1 and 5 years since the coverage was issued: $50 fee (the change will take effect according to the insured’s age at issue and the original rate).
If more than 5 years since the coverage was issued: No fees (the change will take effect according to the insured’s attained age and the original rate).
Please make sure that the non-smoker premium and/or cost of insurance for universal life policies at the attained age is to the client’s advantage compared to the smoker
premium/cost of insurance currently in effect.
Yes
Attach form F3A for each joint insured under this coverage.
Critical Illness
Child Life & Health Duo
Attach form F3A.
Disability
Life and Serenity 65 Attach forms F3A and Q9A.
Alternative Attach form F35A completed through the end of step 1.
Perspective Attach form F35A completed through the end of step 1.
Alternative Term Insurance Attach form F35A completed through the end of step 1.
Transition Simplified Issue Attach form F35A completed through the end of step 1.
Access Life Attach form F35A completed through the end of step 1.
These forms must be completed for each insured
for whom the change is applied.
Amount: $ __________________________ OR Reference premium* OR Monthly cost + taxes OR Current premium (Trend)
*Minimum premium (For EquiBuild or for a life type coverage prior to Genesis 9)
Insured (last and first name)
1. ___________________________________________
When was the last time you used tobacco in any form
(including cigarettes, cigars, cigarillos, marijuana mixed
with tobacco, electronic cigarettes, gum, patches)?
Never
X____________________________________________
Insured signature
More than a year ago
X____________________________________________
Insured signature
Within the past year
Non-eligible
Insured (last and first name)
2. ___________________________________________
When was the last time you used tobacco in any form
(including cigarettes, cigars, cigarillos, marijuana mixed
with tobacco, electronic cigarettes, gum, patches)?
Never
X____________________________________________
Insured signature
More than a year ago
X____________________________________________
Insured signature
Within the past year Non-eligible
Insured (last and first name)
3. ___________________________________________
When was the last time you used tobacco in any form
(including cigarettes, cigars, cigarillos, marijuana mixed
with tobacco, electronic cigarettes, gum, patches)?
Never
X____________________________________________
Insured signature
More than a year ago
X____________________________________________
Insured signature
Within the past year Non-eligible
MANDATORY INFORMATION
Policy no.
Agency Agent
SU
Amount received
$
Reserved for H.O.
Agency code
Agent code
Date (yyyy-mm-dd) Initials
• TOBACCO STATUS (CHANGE TO NON-SMOKER)
• NON-SMOKER BONUS (INCREASE IN COVERAGE)
Policyowner’s last and first name
REQUEST FOR CHANGE
LIFE AND CRITICAL ILLNESS INSURANCE
F4A-06
June 2020
F4A-06(20-06)
