I/We am/are the policy owner(s) of
The Equitable Life Insurance Company of Canada (the”Company”) Policy number
I/We declare that the Policy contract has been lost and is no longer in my/our possession.
I/We request the Company provide me/us with a replacement policy.
I/We will pay Equitable Life of Canada the applicable administration fee set out below for providing me/us with the
replacement policy. If I/We request only a summary of the Policy, there will be no administartion fee.
I/We agree that should I/we find the original Policy, I/we will immediately return the replacement Policy to the Company.
Below is my/our mailing address to be used for delivery of the replacement Policy:
Address
City Province Postal code
Policy owner signature:
Policy owner name:
Policy owner signature:
Policy owner name:
Date:
Substantial copy – $50.00 Policy summary – No charge
REQUEST FOR A REPLACEMENT POLICY FOR A LOST POLICY
TH E EQ UI TA BL E LI FE I NS UR AN CE C OM PA N Y O F C A N A D A
42(2016/12/30)
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.722.6615 T 519.886.5210
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 1.800.722.6615.
