Following the redemption of the investments held with ___________________________ (the “transferor”) and their transfer to the above-mentioned
contract (the “Contract”), transfer fees, such as deferred sales charges, apply. Transfer fees charged by the transferor are estimated at
$ ___________________ (the “transfer fees”).
To offset the transfer fees, Industrial Alliance Insurance and Financial Services Inc. (hereafter referred to as the “Company”) agrees to
reimburse an amount equal to the lesser of: i) the actual transfer fees, and ii) the commission payable to the agent. The commission payable
to the agent will be adjusted according to the administrative policies currently in effect at the Company. A statement detailing the transfer fees
must be attached to this form.
The amount of the reimbursement will be invested in the Contract as additional units of segregated funds according to the same instructions
as per the transfer.
The segregated fund units credited to the Contract will be subject to sales charge options as provided for in the Contract and as explained by
the agent.
For a registered plan, the reimbursement is not a new RRSP or RESP contribution. For a non-registered Contract, each client has a different
tax situation and it is the Applicant’s responsibility to obtain any tax advice.
All signed at __________________________________________________________ this ________ day of ________________________ 20_______.
X ________________________________________________________________________________ X ________________________________________________________________________________
Applicant or Subscriber’s signature Agent’s signature
FundSERV contract
Dealer code Intermediary code
Annuitant’s first and last name (in block letters)Contract no. or application (NP) no.
Agent’s telephone number Extension
Agency code
Agent code
September 2016
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.