POLICY LOAN AGREEMENT
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.668.4095 F 519.883.7404
THE EQUITA B L E L I F E I N S U R A N C E C O M PA N Y O F C A N A D A
680(2016/12/30) Page 1 of 2
Policy Number (the “Policy“) Policyowner(s)
The undersigned request The Equitable Life Insurance Company of Canada (the “Company“) to grant a loan to the undersigned upon the
security of the Policy for the amount of Dollars.
Will this loan be used to fund the purchase of a New Life insurance contract? Yes £ No £
For Universal Life Policies a policy loan is available based on the cash surrender value of the Guaranteed Deposit Accounts and the Daily
Interest Account. A request to transfer funds from your Linked Interest Option Accounts and/or Segregated Funds to the Guaranteed Deposit
Accounts or Daily Interest Account may provide you with a larger loan amount being made available. Should you wish to make such a transfer,
please complete the following section.
I request the following transfers:
$ from the to of months (if applicable)
$ from the to of months (if applicable)
In consideration of this loan, the undersigned: a) assigns the Policy and all monies payable under the Policy to the Company as security for the
loan; b) agrees interest shall be calculated from the effective date of the loan; and, c) agrees to the applicable interest rate below being charged:
£ For policies issued before January 1, 1975,
interest compounded annually, shall be charged
at a rate as stated in your Policy.
The interest rate for this loan is
%
£ For policies issued before January 1, 1975 and later,
interest compounded annually, shall be charged at a variable
interest rate set by the Company from time to time.
The variable interest rate on the effective date of this loan is
%
When the amount of all Policy loans, all unpaid Policy premiums and all accrued interest equals the Policy’s cash surrender value
(including dividends kept in the Policy), the Policy shall lapse.
If a loan is taken in excess of the Adjusted Cost Base on the Policy, a tax slip(s) will be issued in the amount of the gain.
(No tax slip will be issued where the disposition is below the minimum required.)
The undersigned certify that all persons joining with the Policyowner(s) in this agreement are over the age of majority, have signed
of their own free will, and that all covenants and agreements shall be joint and several.
Signature of Policyowner Signature of Policyowner
†
Signature of Assignee(s) (seal) Signature of beneficiary(ies)(if Preferred or Irrevocable)
Date *Policyowner’s Social Insurance Number
† If the Policy is assigned, assignee’s signature alone is sufficient. The signature of 2 signing officers or 1 officer and a seal is required.
* In accordance with Section 237 of the Income Tax Act, we are now required to submit a S.I.N. on all tax forms. Failure to supply
a S.I.N. may result in a penalty payable by you according to Section 162 (5), (6) & (7).
or
