Amount ($): Preferred withdrawal date:*
(This amount is considered ‘fixed’) (1st - 28th) of each month
Pivotal Select policies only:
Payment frequency:
One–time withdrawal
Monthly (1st - 28th)
Semi-monthly (1st & 15th)
Bi-weekly Select day: Monday Tuesday Wednesday Thursday Friday
Automatic Payment Increase Option: Automatically increase my PAD amount by (indicate $ or %)
If elected, the increase will occur on an annual basis and will take effect on the first scheduled withdrawal date of each year.
Life Insurance and Critical Illness policies only:
Payment frequency:
One–time withdrawal
Monthly (1st - 28th)
In the event of non-payment due to insufficient funds (NSF), an attempt to re-draw your payment will automatically occur within
2 – 10 business days from the withdrawal date. The payor is responsible for any NSF charges incurred by their financial institution.
378(2020/07/13) Page 1 of 2
Head Ofce
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. 740 4
1. General Information
2. Banking Information
3. Withdrawal Information
The Equitable Life Insurance Company of Canada (“Equitable Life) and my/our financial institution are directed and authorized
to process withdrawals from my/our account, subject to the conditions below, for the purpose of collecting premiums as follows:
Policy number(s)
Name of policy owner Name of additional policy owner (if applicable)
Owner’s email address Name of payor(s)*
*If the name of the payor is different from policy owner(s) also complete Third Party Information Form (form #31).
Change / Establish new PAD using:
The account shown on the attached VOID cheque or bank letter of direction (payor name is required on the cheque)
The account shown on the first cheque provided with the application
Use existing PAD from Equitable Life policy number: (void cheque not required)
• Line of credit accounts or credit cards are not acceptable payment options.
• For Tax-Free Savings Accounts at least one of the payors must be the owner of the policy.
*This option is not available on Universal Life policies as the withdrawal
date will be the same as the anniversary date.
378(2020/07/13) Page 2 of 2
5. Waivers
For the purposes of this agreement, all PAD withdrawals from my/our bank account will be treated as personal withdrawals of
insurance premiums, as defined by the Canadian Payments Association in Rule H1 at I/we waive the right to
receive pre-notification of the first withdrawal, any increases in the fixed amount of the automatic withdrawal or a change in the
date of the withdrawal.
Cancellation: This PAD shall remain in effect until I/we notify Equitable Life of cancellation. To ensure cancellation of the next
withdrawal, notice by way of telephone, letter, email or fax must be received at the head office of Equitable Life 10 business days
prior to your next withdrawal. Contact us about your rights regarding cancellation. (A sample cancellation form is available at www. that can be completed and forwarded to your financial institution). I/we have the right to cancel this PAD at any time.
Any cancellation of this PAD will not affect the policy contract(s) between you and Equitable Life so long as payment is provided by
an alternate method within the period specified in your policy contract(s).
Recourse and Reimbursement: I/we have certain recourse rights if any withdrawal does not comply with this PAD. I/we have the
right to receive reimbursement for any withdrawal that is not authorized or is not consistent with this PAD. To obtain more information
on recourse rights, please contact Payments Canada or visit
Contact Information:
Equitable Life, One Westmount Road North, P.O. Box 1603 Stn. Waterloo, Waterloo, ON N2J 4C7
TF 1.800.668.4095 T 519.886.5210 F 519.883.74 0 4 Email:
4. Investment Allocation (use for Savings & Retirement investment policies only)
Complete this section if you wish to specify the investments your PAD deposits will be allocated to. If this section is left blank, your future
deposits will be allocated according to the existing investment instructions on your file.
Investment Name
(include fund code if applicable) Allocation % Investment Name (include fund code if applicable) Allocation %
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, Equitable 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.
6. Date and Signature
Note: If withdrawals are to be made from a joint account both account owners must sign if your financial institution requires both signatures.
All signatures for withdrawals from my/our account are present in this PAD, and all terms and conditions printed above are
understood and agreed upon.
Date (dd/mm/yyyy) Signature(s) of payor(s) Signature of policy owner(s) (only required if different than payor(s)
Note: If the payor is a corporation, provide corporation’s legal name, signature, name and title of signing officer(s), and corporate
seal (if available).
Legal name of corporation
Signature(s) Print Name(s) Title(s)