Transfers requested using this form are in-kind transfers. A transfer in-kind refers to the transfer of assets and retention of contract features. This transfer
must be within the same product type. Following this transaction, a new account with same provisions as the original account will be issued.
In this form, the terms you, your and owner refer to the Policyholder of the contract. The terms we, our and us refer to Industrial Alliance Insurance and
Financial Services Inc. This form is used to request full internal and external transfers for Client, Nominee and Intermediary accounts. An internal transfer
involves a transfer between different account types. An external transfer involves a change in dealer.
Notes:
For an agent change on a Client Name account, an Agent Change form and request from the client must be submitted.
For an agent change on a Nominee or Intermediary account, a request from the Nominee or Intermediary must be submitted.
If a change in account type involves a transfer to a RRIF/LIF/RLIF, form F12A must be submitted.
1
TRANSFER DETAILS (The full contract value will be transferred)
FROM:
Current Dealer/Intermediary:
Name _____________________________________ Dealer/Intermediary Code ___________________ Dealer Account ID ____________________
Account Designation: Client Name Nominee Intermediary Intermediary Account ID ________________
Account Type: Non-Registered RRSP LIRA Locked-in RRSP RLSP
TFSA RRIF LIF RLIF PRIF
TO:
New Dealer/Intermediary:
Name _____________________________________ Dealer/Intermediary Code ___________________ Dealer Account ID _____________________
Account Designation: Client Name Nominee Intermediary Intermediary Account ID ________________
Account Type: Non-Registered RRSP LIRA Locked-in RRSP RLSP
TFSA RRIF LIF RLIF PRIF
2
ACKNOWLEDGEMENT OF CURRENT NOMINEE/INTERMEDIARY
The current Nominee/Intermediary trustee agrees to transfer all rights of the contract to the receiving Nominee/Intermediary trustee.
X____________________________________________________________________________________________ ________________________________
Authorized signature of current Nominee/Intermediary Date
3
IRREVOCABLE BENEFICIARY
If an irrevocable beneficiary has been designated, his or her written consent is required prior to completion of this transfer. An irrevocable beneficiary who is a
minor cannot provide consent. By signing this form, any rights that the irrevocable beneficiary may have or any benefits that may otherwise have been
payable to such beneficiary will cease to apply. No rights will continue under the new contract unless the same beneficiary is specifically designated in the
new contract.
X____________________________________________________________________________________________ ________________________________
Signature of Irrevocable Beneficiary Date
X____________________________________________________________________________________________ ________________________________
Signature of Witness Date
Agency code
Agent code
Agent
S.U.
Contract no.
FundServ contract
Dealer code Intermediary code
Annuitant’s first and last name (in block letters)
Complete if changing to a
nominee/intermediary Registered plan.
Agent’s telephone number
Check here if this document was already sent by fax.
COPY 1: COMPANY COPY 2: AGENT COPY 3: CLIENT
F51-220A
INTERNAL/EXTERNAL TRANSFER FORM
INDIVIDUAL SAVINGS AND RETIREMENT
March 2016
F51-220A(16-03) PAGE 1 OF 2
4
BENEFICIARY CHANGE
The death benefit will be paid to the legal heirs if no beneficiary is appointed.
If the Dealer/intermediary Trustee is changing to a Registered Nominee or Intermediary plan, the current policyholder hereby transfers all rights
of the contract to the receiving trustee and agrees that any previous beneficiary designation is revoked. Following completion of the transfer, the
beneficiary on the contract will be the new Trustee of the Nominee/ Intermediary Registered Plan.
For a Non-Registered Nominee/Intermediary or Client Name plan, the existing beneficiary can continue or a new beneficiary may be appointed:
• Existing beneficiary Yes No
• New Beneficiary(ies):
Beneficiary’s first and last name Gender Age %Share Type * Relationship to the applicant (residents of Quebec) or
relationship to the annuitant (residents outside Quebec)
M Revocable*
_______________________________________
F ___________________________ Irrevocable* ________________________________________
M Revocable*
_______________________________________ F ___________________________ Irrevocable* ________________________________________
For a Non-Registered Nominee/Intermediary or Client Name plan, the death benefit will be paid to the legal heirs if no beneficiary is appointed.
X____________________________________________________________________________________________
Signature of Irrevocable beneficiary(ies)
X____________________________________________________________________________________________
Signature of Irrevocable beneficiary(ies)
5
CLIENT NAME REGISTERED ACCOUNT
Request for registration for change from a Registered Nominee/Intermediary account to a Registered Client Account
I hereby request the registration of this contract in accordance with section 146 of the Canada Income Tax Act, with the necessary tax authorities.
6
ANNUITANT’S AND POLICYHOLDER’S AUTHORIZATION
By signing this section you confirm that:
The information provided is fully complete and accurate.
The Nominee/Intermediary named in the Application is your duly authorized agent for all matters related to this Contract.
You authorize Industrial Alliance Insurance and Financial Services Inc. to deliver the Contract and any other documents or correspondence to the
Nominee/Intermediary and to accept instructions from the Nominee/Intermediary to execute the financial and non-financial transactions
including, but not limited to, subscribing to an annuity Contract, purchases, surrenders and transfers of investment vehicles in accordance with
your instructions and Contract provisions.
You authorize Industrial Alliance Insurance and Financial Services Inc. to accept Premiums for investment in this Contract and to pay partial and
total surrender amounts requested by the Nominee/Intermediary directly to the Nominee/Intermediary. You understand that Industrial Alliance
Insurance and Financial Services Inc. shall not be liable for instructions provided by the Nominee/Intermediary.
X____________________________________________________________________________________________
Signature of Policyholder
X____________________________________________________________________________________________
Signature of Annuitant (if different than Policyholder)
X____________________________________________________________________________________________
Signature of Nominee/Intermediary as Trustee (In Registered Plans only)
All signed at _____________________________________________________ this ________________ day of __________________________ 20 ________
For a client account, a Limited Trading Authorization can be completed to authorize the Agent to make transactions on your behalf
COPY 1: COMPANY COPY 2: AGENT COPY3 : CLIENT
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
ia.ca
March 2016
F51-220A(16-03) PAGE 2 OF 2
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