Fillable OWNERSHIP CHANGE FORM (Equitable Life of Canada)

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OWNERSHIP CHANGE FORM (Equitable Life of Canada)

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The OWNERSHIP CHANGE FORM (Equitable Life of Canada) form is 6 pages long and contains:

  • 5 signatures
  • 70 check-boxes
  • 92 other fields

Country of origin: CANADA
File type: PDF

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Category Document Type Document Issuer
Document/Account
Number
Document Date
(dd/mm/yyyy)
Date Advisor Verified
(dd/mm/yyyy)
Category A - Name and address, Category B - Name and date of birth, Category C - Name and account information.
This form has been prepared for the convenience of the policyowner. The Company does not assume responsibility for its validity or sufficiency.
671OC(2021/04/02) Page 1 of 6
The Equitable Life Insurance Company of Canada
1. CHANGE OF OWNERSHIP
If the beneficiary is revocable, this transfer of ownership terminates the existing beneficiary designation. The new owner(s) should complete the
Beneficiary Change Request (form #671BCF), otherwise the policy proceeds become payable to the new owner(s) estate(s).
For Whole Life, Universal Life and Non-Registered policies only: If the new owner is an entity, you must also complete and remit
Business Information Form (form #594).
I/We understand this address will be used as the premium billing address unless other instructions are received by the Company. I/We consent
to policy related documentation, including current annual policy statement, being provided to the new policy owner, and transfer all rights and
interest in the above policy, absolutely and irrevocably, subject to the terms and conditions of the policy to:
OWNERSHIP CHANGE FORM
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo Ontario N2J 4C7
TF 1.800.668.4095 T 519.886.5210 Fax 1.519.883. 7404
www.equitable.ca
New Policyowner: Date of birth (dd/mm/yyyy):
Address (Street, City, Postal code):
Telephone number: Social Insurance Number (SIN):
Occupation (job title and duties) - if not currently working, indicate former occupation:
Verification of Identity: Your Canadian identification must be verified by your advisor. Choose one of the following: provincial driver’s licence,
provincial photo identification card (excluding provincial health cards), passport, citizenship card (issued prior to 2012), permanent resident card,
or Secure Certificate of Indian Status.
Confirmation by advisor (choose one):
I, the advisor, when meeting with the Owner in person, have held and viewed the authentic, valid and current photo identification of the
Owner. Provide details:
If you do not have one of the pieces of identification indicated above, or if this is not being completed in person, please go to
www.equitable.ca/go/alternative-identification for information on our alternative identification requirements.
I, the advisor, have followed the alternative identification instructions, including reviewing two valid and current documents from different
Categories as set out in the instructions. Provide details:
Life insured(s) or annuitant(s): Current policyowner(s):
Policy #: Policy #: Policy #:
Is this Ownership Change being submitted with a policy change? (For Life Insurance only)
No Yes
If yes, the changes apply to: (Select only one option)
Current Policy Only
New Policy Only
Both Current and New Policy
The following information is required to comply with Canadian legislation. In order for us to process your Ownership Change, please fill out all
fields in the applicable sections.
Identification Type Identification Number Issuing Jurisdiction/Country
Expiry Date
(yyyy/mm/dd)
Date Advisor Verified
(yyyy/mm/dd)
Category Document Type Document Issuer
Document/Account
Number
Document Date
(dd/mm/yyyy)
Date Advisor Verified
(dd/mm/yyyy)
671OC(2021/04/02) Page 2 of 6
1. CHANGE OF OWNERSHIP (Cont.)
If joint owner complete below:
The Equitable Life Insurance Company of Canada
Category A - Name and address, Category B - Name and date of birth, Category C - Name and account information.
New Policyowner: Date of birth (dd/mm/yyyy):
Address (Street, City, Postal code):
Telephone number: Social Insurance Number (SIN):
Occupation (job title and duties) - if not currently working, indicate former occupation:
Verification of Identity: Your Canadian identification must be verified by your advisor. Choose one of the following: provincial driver’s licence,
provincial photo identification card (excluding provincial health cards), passport, citizenship card (issued prior to 2012), permanent resident card,
or Secure Certificate of Indian Status.
Confirmation by advisor (choose one):
I, the advisor, when meeting with the Owner in person, have held and viewed the authentic, valid and current photo identification of the
Owner. Provide details:
If you do not have one of the pieces of identification indicated above, or if this is not being completed in person, please go to
www.equitable.ca/go/alternative-identification for information on our alternative identification requirements.
I, the advisor, have followed the alternative identification instructions, including reviewing two valid and current documents from different
Categories as set out in the instructions. Provide details:
2. TAX CONSIDERATIONS (not applicable to Critical Illness policies)
Note: • The information in this section is required to determine the tax consequences of the ownership change.
• For information about whether individuals or entities are “related” for tax purposes, please consult your tax advisor.
• If the current owner is deceased and no successor/contingent owner was named for the policy, proceed to Reason for Change question.
Transfers between individuals
If the transfer is between individuals, indicate below the relationship of the current policy owner to the new policy owner (select one):
Current owner New owner
Parent (including adoptive, in-law) > Child
Grandparent (including adoptive, in-law) > Grandchild
Spouse > Spouse
Former spouse > Former spouse
Sibling (including in-law) > Sibling
Individual, other than those listed above, who IS related to the other
individual for tax purposes
>
Individual, other than those listed above, who IS related to the other
individual for tax purposes
Individual who IS NOT related to the other individual for tax purposes > Individual who IS NOT related to the other individual for tax purposes
OWNERSHIP CHANGE FORM
Identification Type Identification Number Issuing Jurisdiction/Country
Expiry Date
(yyyy/mm/dd)
Date Advisor Verified
(yyyy/mm/dd)
671OC(2021/04/02) Page 3 of 6
The Equitable Life Insurance Company of Canada
2. TAX CONSIDERATIONS (not applicable to Critical Illness policies) (Cont.)
Transfers involving a corporation, trust or other entity
If the transfer involves a corporation, trust or other entity, indicate below the relationship of the current policy owner to the new policy owner
(select one):
Current owner New owner
Individual > Trust
Individual who IS related to the corporation for tax purposes > Corporation that IS related to the individual for tax purposes
Individual who IS NOT related to the corporation for tax purposes
Trust > Individual
Corporation that IS related to the individual for tax purposes > Individual who IS related to the corporation for tax purposes
Corporation that IS NOT related to the individual for tax purposes > Individual who IS NOT related to the corporation for tax purposes
Corporation that IS related to the other corporation for tax purposes > Corporation that IS related to the other corporation for tax purposes
Corporation that IS NOT related to the other corporation for tax
purposes
> Corporation that IS NOT related to the other corporation for tax
purposes
Other – specify: > Other – specify:
Reason for change of ownership (select one of the following):
Death of current policy owner
Transfer of policy in settlement of rights arising out of, or on the breakdown of, a marriage or common-law partnership
Wind up of corporation
Amalgamation of corporations
Distribution from a trust to a capital beneficiary of a trust
Donation to a registered charity
None of the above
Consideration paid to the current owner by the new owner
What is the amount of money or the fair market value of the consideration paid (if any) by the new owner to the current owner for the policy?
$____________
OWNERSHIP CHANGE FORM
3. DECLARATION OF TAX RESIDENCE (for Whole Life, Universal Life And Non-Registered Policies only)
New Policy Owner: check all of the options that apply to you.
I am a tax resident of Canada
I am a tax resident or citizen of the United States: Provide Taxpayer Identification Number (TIN) or functional equivalent:
I am a tax resident in a jurisdiction other than Canada or the United States:
Jurisdiction of tax residence TIN or functional equivalent:
If you do not have a TIN or functional equivalent for a specific jurisdiction, choose one of the following reasons:
a) I will apply or have applied for a TIN but have not yet received it
b) My jurisdiction of residence does not issue TINs to its residents
Other reason:
671OC(2021/04/02) Page 4 of 6
4. APPOINTMENT OF CONTINGENT POLICYOWNER
I/We revoke all previous designations of contingent policyowners(s) [subrogated holder(s)] under this contract and, upon my death, appoint the
person(s) below to become the policyowner(s) [holder(s] of this contract, if living, otherwise ownership of this contract will automatically transfer
to my/our estate(s).
Full name of contingent policyowner:
Date of birth (dd/mm/yyyy): Social Insurance Number (SIN):
5. THIRD PARTY
Is the Owner acting on behalf of a Third Party?
Your answer should be “Yes” if someone other than the owner or life insured/annuitant will be paying the premium or has/will have an
ownership interest in this policy. Examples include a power of attorney signing on behalf of the owner, someone other than the owner or life
insured/annuitant is paying premiums, or a corporation having use or access to the policy values.
No (If Owner/Insured)
If No continue to section section 6 entitled “Source of funds”.
Yes (If someone other than the Owner/Insured)
If yes, complete the appropriate section; Individual Third Party or Business/Entity Third Party.
Individual Third Party
Type of Third Party (select one and attach any applicable legal documentation)
payor trustee executor collateral/assignee attorney/power of attorney/mandatary
other (please specify):
New Joint Policy Owner: check all of the options that apply to you.
I am a tax resident of Canada
I am a tax resident or citizen of the United States: Provide Taxpayer Identification Number (TIN) or functional equivalent:
I am a tax resident in a jurisdiction other than Canada or the United States:
Jurisdiction of tax residence TIN or functional equivalent:
If you do not have a TIN or functional equivalent for a specific jurisdiction, choose one of the following reasons:
a) I will apply or have applied for a TIN but have not yet received it
b) My jurisdiction of residence does not issue TINs to its residents
Other reason:
3. DECLARATION OF TAX RESIDENCE (FOR WHOLE LIFE, UNIVERSAL LIFE AND NON-REGISTERED POLICIES ONLY) (Cont.)
The Equitable Life Insurance Company of Canada
OWNERSHIP CHANGE FORM
Name of Third Party (first, middle, last) Date of Birth (dd/mm/yyyy) Phone number
Address (number, street and apartment) City or Town
Province and Country Postal Code
Realtionship to owner Occupation (job title and duties) –
if not currently working, indicate former occupation
671OC(2021/04/02) Page 5 of 6
OWNERSHIP CHANGE FORM
6. SOURCE OF FUNDS
Check all that apply:
Salary or Earned Income Business Income
Sale of Property Borrowed Funds
Gifted Funds Proceeds from Death Benefits or Estate
Applicant / Owner Savings Other:
7. PURPOSE OF THE POLICY
Check all that apply (for Life or Critical Illness Insurance policies, select at least one of the
bolded
options. Not all policies are suitable for all
purposes):
Short Term Savings Retirement / Long Term Savings
Business / Key Person Protection / Buy Sell Agreement
Income Creation Gift
Income / Family Protection
Legacy / Inheritance / Estate Protection
Mortgage / Debt Insurance
Education Purposes
Other
Relationship to Owner Nature of principal business
Incorporation / Registration Number (if applicable) Jurisdiction / Country of Issue (if applicable)
Business / Entity Third Party
Full Legal Name
Address (number, street and apartment) City or Town Province
Phone Number Postal Code Country
The Equitable Life Insurance Company of Canada
671OC(2021/04/02) Page 6 of 6
OWNERSHIP CHANGE FORM
9. INSTRUCTIONS FOR NAME AND OWNERSHIP CHANGES
1. Please ensure all information is printed clearly and legibly on the form.
2. This form may be used to make identical changes to more than one policy, if the insured/annuitant(s) and owner(s) are the same for each
policy.
3. For Whole Life, Universal Life and Non-Registered policies only: If the new owner is an entity, you must also complete and remit Business
Information Form (form #594).
4. A change of ownership may have tax consequences. Please contact your tax advisor before making changes.
5. A change of ownership may affect the interest of beneficiaries elected prior to the date of ownership change.
6. Signature requirements: when the form is completed by a:
• corporation: the full name of the corporation must be printed with authorized person(s) signature and title mentioned.
• partnership or firm: the full name of the partnership or firm must be printed with signatures of all partners.
• sole proprietorship: the sole proprietor must sign the form with sole proprietor written beside the signature.
7. A transfer of ownership is not permitted under a registered policy.
8. The ownership of a G3 (issue date of January 1, 2017 or later) multiple life term insurance policy cannot be transferred to a company.
9. The policy owner(s) must initial any changes made to the form.
10. Due to the recent change(s) to your policy, you may be required to update your Client Access to reflect the changes.
This form has been prepared for the convenience of the policyowner. The Company does not assume responsibility for its validity or sufficiency.
Please note: Equitable Life
®
cannot ensure the privacy and confidentiality of any information sent through the internet because e-mail may be vulnerable to interception. As a result, Equi-
table Life is not responsible for any loss or damages you may incur if your information is intercepted and misused. If you would prefer to submit your information by another means, please
contact us at 1.800.668.4095.
8. SIGNATURES
I certify that the information provided on this form is current, correct and complete. I will notify Equitable Life within 30 days of any change to my
tax residency, US citizenship status or tax identification numbers.
Signed at
(city) (province) this (day) of (month) (year)
Ownership Change – Required Signatures:
Signature of current policyowner(s)
Signature of new policyowner(s)
Signature of assignee (if applicable) Signature of irrevocable beneficiary(ies) (if applicable)
I relinquish all rights as irrevocable beneficiary and consent to the appointment of
a new beneficiary
To the best of my knowledge, the information provided is complete and true. I will notify Equitable Life within 30 days of any change to the
information provided on this form.
Signature of Advisor
The Equitable Life Insurance Company of Canada
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OWNERSHIP CHANGE FORM (Equitable Life of Canada)

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Completed 29 November 2021

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