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F51-153A-1 DEPOSIT REQUEST AND PAD AGREEMENT (OTHER THAN

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F51-153A-1
DEPOSIT REQUEST AND PAD
AGREEMENT (OTHER THAN RESP)
INDIVIDUAL SAVINGS AND RETIREMENT
PAGE 1 OF 4F51-153A-1(19-09)
A
DEPOSIT OF A SUBSEQUENT PREMIUM
One-time pre-authorized debit (Complete section J on page 3.) Transfer from another institution: $________________ (Complete section C.)
Cheque from the client: $_________________ (Minimum $100) (Complete section C.) Loan reimbursement: $_________________
B
CHANGE TO AUTOMATIC INVESTMENT TERM (AIT) – (ATTENTION: PAD AGREEMENT AVAILABLE ON PAGE 3 (SECTION J))
IMPORTANT
The Daily Interest Fund+ (DIF+) and the Guaranteed Interest Fund (GIF) are not offered under Fundserv contracts.
Modify the AIT of the DIF+
Modify the GIF maturity instruction:
Keep investments in the DIF+
Other instructions (Complete section C.)
Investment maturing on
Y Y Y Y M M D D
All GIF investments
Capital and Interest (Complete section C.)
Interest only (Complete section C.)
Capital only (Complete section C.)
C
INVESTMENT INSTRUCTIONS
High Interest Savings Account: _____________ % or $
Daily Interest Fund+ (DIF+): _____________ % or $
If there is an AIT on the contract, the amounts deposited
in the DIF+ will be invested according to the AIT when the
required minimum has been reached.
Investment Funds: _____________ % or $
(Complete the table opposite.)
(ATTENTION: Minimum $5 per fund)
Guaranteed Interest Fund: _____________ % or $
To guarantee the interest rate, form F50-238A
Interest Rate Guarantee Agreement is required.
GIF (For AIT): $500 (par default) or $1,000
Amount Interest Type Term Rate
_____________$
Simple
Compound (Default)
1 month
______ years _______%
_____________$
Simple
Compound (Default) ______ years _______%
Please use table F13-1000A for the investment fund numbers.
The total cash amount or percentage must equal 100% of the premium
to be invested.
Fund no.
If FEL,
% of premiums
% or $
Order no.
1.
2.
3.
4.
5.
6.
D
SPECIAL INSTRUCTIONS
E
DECLARATIONS/SIGNATURES
• By signing below, I request that the transactions indicated in this request be carried out in accordance with the stipulations of the Contract and, if applicable, confirm I have read and agree to the
information and provisions of the PAD Agreement.
• If Fund units are credited to this contract for the first time: I confirm that I have completed electronic investor profile no.
(to be included) or a paper profile
(to be included) with my advisor and I acknowledge receipt of the Information Folder which describes the characteristics of my contract as well as the Fund Facts booklet.
!
___________________________ X___________________________________ X________________________________ X_______________________________
Date Applicant Co-Applicant Advisor*/Witness
* Where there is a deposit of a subsequent lump-sum premium of $100,000 or more for a non-registered annuity contract, I, the life insurance agent, confirm that I have taken reasonable measures
to determine if the owner(s), and the individual making the payment (if he or she is not an owner), are politically exposed persons or heads of an international organization or a family member or
close associate of either; and I have taken reasonable measures to establish the source of the funds. I also confirm that if there is a deposit of a subsequent lump-sum premium of $100,000 or more
and this request is made using the paper format, that I have completed a new form F51-208A and it is attached to this deposit request.
Trade made by Fundserv network: Check here Trade made by Extranet/Web: Check here
Fundserv contract
Dealer code Intermediary code
Annuitant’s first and last name (in block letters)Contract no.
Advisor’s telephone number ExtensionAdvisor
Agency code
S.U.
Advisor code
September 2019
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F51-153A-1
DEPOSIT REQUEST AND PAD
AGREEMENT (OTHER THAN RESP)
INDIVIDUAL SAVINGS AND RETIREMENT
PAGE 2 OF 4F51-153A-1(19-09)
F
RESETS
VERSION RESET
Ecoflex (guarantee 1) Not allowed.
Ecoflex (guarantees 5, 13, 15, 16 and 19)
Not allowed in the 10-year period preceding the maturity date.
Ecoflex (guarantees 6, 12, 17 and 18)
In the 10-year period preceding the maturity date, the maturity date will be deferred by 10 years from the request date.
IAG SRP Ecoflex Series 100/100
(guarantees 11, 21 and 31)
In the 15-year period preceding the maturity date, only the guaranteed minimum value at death will be reset.
This reset will take place once annually until the annuitant’s 80th birthday.
IAG SRP Series 75/100 and
Series 75/100 (Prestige)
(guarantees 11, 21 and 31)
Only the guaranteed minimum value at death can be reset. This reset can be made once annually until the annuitant’s
85th birthday.
IAG SRP FORLIFE Series (guarantee 31)
Only the guaranteed minimum value at death in the Savings stage can be reset. This reset can be made once annually
until the annuitant’s 80th birthday.
G
CHANGE OF MATURITY DATE FOR THE GUARANTEE
VERSION CHANGE OF MATURITY DATE
Ecoflex (guarantee 1)
In the 10-year period preceding the maturity date, this date can be deferred by 10 years from the request date.
This change does not lead to an automatic reset.
Ecoflex (guarantees 5, 13, 15, 16 and 19)
The maturity date must be between the annuitant’s 60th and 71st birthday. No change is permitted in the 10 years
preceding the current maturity date.
Ecoflex (guarantees 6, 12, 17 and 18)
The maturity date must be between the annuitant’s 55th and 69th birthday and must be deferred by 10 years from
the request date.
IAG SRP Ecoflex Series 100/100
(guarantees 11, 21 and 31)
The maturity date must be between the annuitant’s 60th and 71st birthday. No change is permitted in the 15 years
preceding the current maturity date.
IAG SRP Series 75/100 and
Series 75/100 (Prestige)
(guarantees 11, 21 and 31)
Not allowed.
IAG SRP FORLIFE Series (guarantee 31) Not allowed.
Enter the new guarantee maturity date:
Y Y Y Y M M D D
H
SPECIAL INSTRUCTIONS
I
DECLARATIONS/SIGNATURES
• By signing below, I request that the transactions indicated in this request be carried out in accordance with the stipulations of the Contract and, if applicable, confirm I have read and agree to the
information and provisions of the PAD Agreement.
• If Fund units are credited to this contract for the first time: I confirm that I have completed electronic investor profile no.
(to be included) or a paper profile
(to be included) with my advisor and I acknowledge receipt of the Information Folder which describes the characteristics of my contract as well as the Fund Facts booklet.
!
___________________________ X___________________________________ X________________________________ X_______________________________
Date Applicant Co-Applicant Advisor*/Witness
* Where there is a deposit of a subsequent lump-sum premium of $100,000 or more for a non-registered annuity contract, I, the life insurance agent, confirm that I have taken reasonable measures
to determine if the owner(s), and the individual making the payment (if he or she is not an owner), are politically exposed persons or heads of an international organization or a family member or
close associate of either; and I have taken reasonable measures to establish the source of the funds. I also confirm that if there is a deposit of a subsequent lump-sum premium of $100,000 or more
and this request is made using the paper format, that I have completed a new form F51-208A and it is attached to this deposit request.
Trade made by Fundserv network: Check here Trade made by Extranet/Web: Check here
Fundserv contract
Dealer code Intermediary code
Annuitant’s first and last name (in block letters)Contract no.
Advisor’s telephone number ExtensionAdvisor
Agency code
S.U.
Advisor code
Validate and print
Save
Validate and print
F51-153A-1
PAGE 3 OF 4F51-153A-1(19-09)
PAD AGREEMENT
(OTHER THAN RESP)
INDIVIDUAL SAVINGS AND RETIREMENT
If these changes must be applied to other contracts, please list their numbers here:
–
–
–
J
PRE-AUTHORIZED DEBIT AGREEMENT (PAD) GENERAL INFORMATION
!
Allow 3 days for all changes
IMPORTANT
If the bank account owner’s signature is required, you must provide him/her with a copy.
1. Indicate if it’s a: Instructions Signature ( See below if bank account owner’s or advisor’s
signature is required.)
Regular PAD or onetime PAD enrolment
Complete regular PAD or onetime PAD section Signature of bank account owner mandatory
Reactivation of the regular PAD
Confirm PAD information if modification to banking information
Client or advisor without LTA
(
!
Except for modification of banking information with changes
to the payer, Signature of bank account owner is mandatory)
Modification to banking information
With change of payor Signature of bank account owner mandatory
Without change of payor Client or advisor without LTA
Modification to a regular PAD
Complete regular or loan PAD section
Signature of client or advisor without LTA
(
!
Except for AIT for PAD, the LTA is required)
Modification of a loan PAD
Complete regular or loan PAD section Client or advisor without LTA
Termination of a PAD
After PAD dated:
Y Y Y Y M M D D
Immediate (Default)
Client or advisor without LTA
2. Withdrawal Agreement: Variable
3. PAD Category:
Personal Business (If both boxes are left unchecked, the PAD category will be deemed “Personal”)
4. PAD Information
ATTENTION: Minimum $5 per fund
Type
Date
(
!
Mandatory)
Amount
(
!
Mandatory)
Frequency Investment Instructions
Regular or
loan PAD
Date of PAD:
Y Y Y Y M M D D
$__________
Monthly (Day 1 to 28). Day: _______
Last day of each month
(Not available for the loan PAD)
Weekly.
Day: _______________
(Monday to Friday)
Every two weeks.
Day: _______________
(Monday to Friday)
AIT on PAD (Regular PAD not available for the Income Stage of the FORLIFE Series):
Investment Funds: _______ %
% %
% %
High Interest Savings Account: _______ %
Daily Interest Fund+ (DIF+): _______ %
Guaranteed Interest Fund (GIF)*
* To invest in a GIF, a AIT on the DIF+ is mandatory.
One-time
withdrawal
Date of one-time PAD:
Y Y Y Y M M D D
Immediately
$__________ Not applicable
Investment Funds: _______ %
% %
% %
High Interest Savings Account: _______ %
Daily Interest Fund+ (DIF+): _______ %
Guaranteed Interest Fund (GIF): Interest type: _________
_______ % Term: _______________
Rate: _______________
5. Banking Information: (Attach a void cheque or attach a written confirmation duly completed by the financial institution.)
Branch number:
Financial institution number: Account number:
Name of the account owner(s): _______________________________________________________________________________________________________________________________________________________
6. PAD Agreement and Signatures
• By signing below, I request that the transactions indicated in this request be carried out in accordance with the stipulations of the Contract and confirm I have read and agree
to the information and provisions of the PAD Agreement.
• For a joint account, all required signatories must sign this PAD Agreement
• For a company, the PAD agreement must be signed by all required authorized signatories. Attach a copy of the company’s resolution stipulating the required authorized signatories.)
!
___________________________ X___________________________________ X________________________________ X_______________________________
Date Account owner’s signature Co-account owner’s signature Advisor/Witness
Trade made by Fundserv network: Check here Trade made by Extranet/Web: Check here
Fundserv contract
Dealer code Intermediary code
Annuitant’s first and last name (in block letters)Contract no.
Advisor’s telephone number ExtensionAdvisor
Agency code
S.U.
Advisor code
Term / Interest type:
Save
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F51-153A-1
PAGE 4 OF 4F51-153A-1(19-09)
Pre-Authorized Debit (PAD) Agreement
In this PAD Agreement each owner is referred to as “I” and makes the following statements in respect to himself or herself:
• I authorize Industrial Alliance Insurance and Financial Services Inc. (“iA Financial Group”) and the financial institution designated (or any other institution I may authorize at
any time) to begin deductions as per my instructions for regular recurring payments and/or one-time payments from time to time for payment of all premiums, deposits,
installments and charges arising from the Contract mentioned herein;
• Regular payments will be debited on the date and at the frequency I have chosen, whereas one-time payments from time to time can be debited from my account
on any other date. Regular and/or one-time payments will be debited in accordance with the banking information set out in the Electronic Application;
• I agree that, for the purpose of this PAD Agreement, all PADs from my account will be treated as Personal or Business* depending on the choice I have made
on the Electronic Application;
• I waive the right to receive pre-notification of an increase or decrease in the amount to be debited or a change in the date and/or frequency of these payments;
• I agree that iA Financial Group is not required to provide me with written notice of a change in a PAD amount that is made as a result of my request;
• If a PAD is dishonoured for any reason such as, but not limited to, insufficient funds (“NSF”) or stop payment, iA Financial Group is authorized to resubmit the payment.
Any charges incurred by iA Financial Group as a result of a dishonoured PAD will be added to the subsequent PAD;
• I may cancel or change this PAD Agreement at any time, subject to providing iA Financial Group thirty (30) days notice in writing. To obtain a sample cancellation form or
for more information on my right to cancel the PAD Agreement, I may contact my financial institution or visit www.payments.ca regarding Rule H1 – Pre-authorized
debits (PADs);
• Any cancellation of this PAD Agreement will not affect my insurance contract(s) and/or contract(s) for financial services, so long as payment is provided by an
alternate method;
• iA Financial Group will not assign this PAD agreement without providing me the full details of the assignment a minimum of ten (10) days in advance of any PAD being
issued in the assignee’s name;
• I have certain recourse rights if any PAD does not comply with this PAD Agreement. For example, I have the right to receive reimbursement for any PAD that is not
authorized or is not consistent with this PAD Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.payments.ca
regarding Rule H1 - Pre-authorized debits (PADs);
• Before iA Financial Group debits the first PAD payment, it must receive all required documents, duly completed and be allowed a reasonable period of time to complete its
administrative processes.
*Business PAD means a PAD for the payment of goods or services related to a business or commercial activity of the payor.
Telephone number: 1-844-4iA-INFO (1-844-442-4636) Information: savings@ia.ca
Quebec:
1080 Grande Allée West
PO Box 1907, Station Terminus
Quebec City, QC G1K 7M3
Fax: 1-855-685-5161
Transactions: IAQtransactions@ia.ca
Toronto:
522 University Ave., Suite 400
Toronto, ON M5G 1Y7
Fax: 1-800-810-0197
Transactions: IATtransactions@ia.ca
Vancouver:
400-988 West Broadway
PO Box 5900
Vancouver, BC V6B 5H6
Fax: 1-833-832-7474
Transactions: IAV-transactions@ia.ca
PAD AGREEMENT
(OTHER THAN RESP)
INDIVIDUAL SAVINGS AND RETIREMENT
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
ia.ca
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F51-153A-1 DEPOSIT REQUEST AND PAD AGREEMENT (OTHER THAN

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