Instructions for completing this form
In this form, the terms “you”, “your”, “my” and “owner” refer to the policy owner(s). The terms “we”, “our” and “us” refer to
The Equitable Life Insurance Company of Canada (Equitable Life). An advisor can complete this form if there is “Limited Trading
Authorization” on ﬁle. This will void the current and any previous reset guarantees.
1. Contract details
Name of Policy Owner(s)
693SEL(2020/02/24) Page 1 of 6
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
INVESTMENT DIRECTION – PIVOTAL SELECT
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.668.4095 T 519.886.5210 F 519.883.7404
2. Political positions (for non-registered and only when deposit is equal to or greater than $100,000)
For the purposes of this question:
• “Payor” means the person who is making the payment(s) on the policy.
• “Close relative” means the Payor’s spouse, sibling, parent, spouse’s parent, child, or child’s spouse.
• “Close associate” means an individual who is closely connected to the Payor for personal or business reasons.
Does the Payor, any of the Payor’s close relatives or any of the Payor’s close associates hold, or have they ever held, any of the
positions listed below?
No – go to Section 3 Yes – indicate the political position below
Position in Canada or in another country
Note: For positions in Canada, list only the positions held in the past five years. For all other countries, list all such positions that have ever been held.
Head of state or head of government (including
governor general and lieutenant governor)
President of a state-owned company or bank
(including a corporation that is wholly owned
by a federal or provincial government)
Member of the executive council of government
or member of a legislature (including the Senate,
House of Commons or a provincial legislature)
Head of a government agency
Judge (in Canada only, must be a judge of an
Head of an international organization that is established by the
governments of countries or the head of an institution of any
Deputy minister (or equivalent)
Leader or president of a political party in a legislature
Ambassador or ambassador’s attaché or counsellor
Military general (or higher rank)
Mayor of a Canadian municipality (does not include mayors in
countries other than Canada)
If you answered “Yes” to the question above, complete the following information:
What is the name of the person who holds or held
What is the title of the position held?
Position held from:
In what country was the position held?
With what organization, government or institution was
the position held?
How is this person related to the Payor?
The person is the Payor
Close relative (relationship):
Close associate (relationship):
Note: If more than one person has held a position, complete section 1 and 2 of the “Additional/Updated Customer Information Form # 1027”
for each additional person.