PRE-AUTHORIZED DEBIT PLAN (“PAD”)
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
378(2020/07/13) Page 2 of 2
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 www.payments.ca. 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.
payments.ca 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 www.payments.ca
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: email@example.com
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.
(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)