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F17A-1
APPLICATIO N
TFSA
Tax-Free Savings Account
SAVINGS
March 2021
NOTE FOR THE AGENT
You must:
–
Produce 3 copies of this application
–
Send the original copy to head office
–
Keep a copy for your files
–
Give a copy to the client
REQUIRED DOCUMENTS
If applicable, you must send the following documents with this application:
–
The investor profile if Fund Units are credited to the Contract
–
Copy of the transfer form (you must send the original directly to the other institution)
INSTRUCTION
Once you have finished and you are ready to continue with
your electronic signature tool, please use the Finalize!
button for the electronic signature.
If the Contract is held in a Nominee or Intermediary
Account, it must be administered through the Fundserv
network.
If a Contract is registered externally and held in a Nominee
or an Intermediary Account, it will be considered to be
a non-registered contract by Industrial Alliance Insurance
and Financial Services Inc.
The Holder must be at least 18 years of age when
he/she signs the Application.
If the Contract is held in a Registered Nominee or
Intermediary Account, the Annuitant is automatically
the Registered Nominee or Intermediary Account holder.
Agency
Secondary agent
Only one agent is authorized for contracts
administered through the FundSERV network.
Important – Agent code must be active.
Held: in the Client’s Name, OR in a:
Nominee Account – Name of the Nominee: _________________ Nominee Account Number: ______________________
Intermediary Account – Name of the Intermediary: ____________ Intermediary Account Number: ___________________
Tax-Free Savings Account (TFSA)
First name: ____________________________________ Last name: _______________________________________
SIN (mandatory): Date of birth:
Gender: Female Male Language: English French
Tel. (home):
Email: __________________________________________
Tel. (office): ext.
Cell.:
Address: _________________________________________________________________________________________
Number, street Apt., PO Box
_________________________________________________________________________________________
City Province Postal code
Agency code: Name of district or agency: ______________________________________________________
Agent code: SU: Agent (commissions only): % of commission _____%
Name of agent: ________________________________
Primary agent
Important – Agent code must be active.
FundSERV code: Sales rep.: ______________________________ Dealer: _____________________________________
OR
Agent code:
SU: Agent (commissions and service): % of commission _____%
Name of agent: ________________________________ Email: ______________________________________________
Telephone: Ext.:
1- Type of Contract
2- Type of Registration
3- Holder/Annuitant
4- Life Insurance Agent
NP
APPLICATION
IAG SAVINGS AND RETIREMENT PLAN APPLICATION
INDIVIDUAL VARIABLE ANNUITY CONTRACT
Contract No.
F17A-1(21-03)
F17A-1
WARNING
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Adobe for Windows product such as Adobe Reader.
Please close this form, save on your Windows desktop, and
open from an Adobe product.
VOID
Beneficiaries
Do not complete if the Contract is held in a Registered
Nominee or Intermediary Account.
If the Contract is held in a Registered Nominee or
Intermediary Account, the Beneficiary
of the Contract is automatically the trustee of the
Registered Nominee or Intermediary Account for
the benefit of the holder of the Registered Nominee
or Intermediary Account.
Notes:
– Surviving Annuitant: If you designate your spouse or
common-law partner as the sole Beneficiary, your
spouse or common-law partner will have the option
to become the Annuitant and Holder upon your
death, in accordance with the terms established in
the Contract.
– Quebec residents: If you name your spouse or civil
union spouse as Beneficiary, the designation is
considered irrevocable unless you check the box
indicating that it is to be revocable.
– If a Successor Annuitant is designated, upon the
Annuitant’s death, the Contract remains in force
and no death benefit is payable to the Beneficiaries
or the estate.
– The Successor Annuitant shall become the Applicant
upon the Annuitant’s death.
– For a registered plan, only the spouse or common-law
partner can be designated.
Trustee for minor Beneficiary
Not applicable where Quebec laws apply.
If a trustee is appointed above, any death benefit to be
paid under the Contract to the minor Beneficiary who,
at the time payment is to be made, is a minor, will be
paid to the trustee, in trust for the minor Beneficiary.
The trust for any minor Beneficiary will terminate once
the Beneficiary is of age of majority. Before completing
the section above, please consult your legal advisor.
1. First name: ___________________________________ Last name: _______________________________________
Date of birth: Percentage: ________ %
Type: Revocable Irrevocable Gender: Female Male
Relationship to the Annuitant: ________________________________________________________________________
2. First name: ___________________________________ Last name: _______________________________________
Date of birth: Percentage: ________ %
Type:
Revocable Irrevocable Gender: Female Male
Relationship to the Annuitant:
________________________________________________________________________
3. First name: ___________________________________ Last name: _______________________________________
Date of birth: Percentage: ________ %
Type: Revocable Irrevocable Gender: Female Male
Relationship to the Annuitant: ________________________________________________________________________
4. First name: ___________________________________ Last name: _______________________________________
Date of birth: Percentage: ________ %
Type: Revocable Irrevocable Gender: Female Male
Relationship to the Annuitant: ________________________________________________________________________
5. First name: ___________________________________ Last name: _______________________________________
Date of birth: Percentage: ________ %
Type: Revocable Irrevocable Gender: Female Male
Relationship to the Annuitant: ________________________________________________________________________
First name: ____________________________________ Last name: _______________________________________
Date of birth:
Relationship to the Annuitant: _________________________________________________________________________
Name of minor Beneficiary Date of birth Name of trustee Relationship to minor
________________________ ______________________ _________________________
________________________ ______________________ _________________________
Contingent Beneficiary
The rights of a Contingent Beneficiary (Subrogated
Beneficiary in Quebec) become in force only in the
event that all primary beneficiaries have died before
the Annuitant or if they have waived their rights as
primary Beneficiaries. A Contingent Beneficiary
(Subrogated Beneficiary in Quebec) remains revocable.
First and last name Gender Date of birth Percentage
1.
______________________________________
Female
Male ________ %
2.
______________________________________
Female
Male ________ %
5- Beneficiaries
6- Designation of a Successor Annuitant
F17A-1(21-03)
Complete only if a Premium is invested in the
Ecoflex Series 100/100 and the Annuitant is less
than 56 years old.
For pre-authorized debit (PAD), please complete
section 13 Pre-Authorized Debit (PAD).
For an internal transfer from an iA contract, form
F51-153A-6 Request for transfer between contracts
is required.
For segregated funds, you must attach a copy of an
investor profile (see section 16 for Electronic profile
details).
Please use table F13-1000A for the investment
fund numbers.
* Contracts administered by the FundSERV network only
The Guarantee Maturity Date must be at least fifteen (15) years from the date Ecoflex Series 100/100 Fund Units are credited for the
first time to the Contract and must be between the Annuitant’s 60th and 71st birthdays.
If the Guaranteed Maturity Date is not specified or is not well established, this date is automatically established by the Company as
the Annuitant’s 71st birthday.
Please refer to the Contract if the Annuitant is age 56 or over; the Guaranteed Maturity Date shall be set at exactly fifteen (15) years
from the Initial Investment Date of Ecoflex Series 100/100.
Guaranteed Maturity Date:
Pre-authorized debit (PAD): $__________________
Client cheque (minimum $100): $__________________
Internal transfer from iA contract: Contract number: __________________________ Amount: $__________________
Transfer from another institution:
Company (Attach transfer form) Approximate amount
____________________________________________________ $ ____________________________________
____________________________________________________ $ ____________________________________
Fundserv trade: $__________________
Table A (Investment funds)
Fund no. If FEL, % of premiums
% or $
Wire order no.*
The Daily Interest Fund+ (DIF+) is not available in
Fundserv contracts.
Minimum for Guaranteed Interest Funds: $500
If no box is checked, investments at maturity will be
transferred to the Daily Interest Fund+, then invested
in accordance with the AIT established for the DIF+,
if applicable.
High Interest Savings Account: ________________________ % or $
Daily Interest Fund+ (DIF+): ___________________________ % or $
Investment funds (segregated funds): ____________________ % or $ (Complete table A below)
Guaranteed Interest Fund (GIF): ________________________ % or $ (Complete table B below)
Table B (Guaranteed Interest Fund)
Amount ($) Rate (%) Term Type of interest
1 month or _____ years Compound (Default) Simple
_________ years
Compound (Default) Simple
Instructions for investments at maturity:
Same term Other instructions, please specify: ________________________________________________________
7- Guaranteed Maturity Date for the Ecoflex Series 100/100
8- Investment Instructions
F17A-1(21-03)
AIT on the Daily Interest Fund+
Not applicable for Income Stage Funds of the
FORLIFE Series.
Not available for Fundserv contracts.
If no AIT instructions are received by the Company, all
Premiums will be invested, according to the applicable
terms of the Contract, in the Daily Interest Fund+ or in
the Money Market Fund and they will stay in the DIF+
or Money Market Fund until the Applicant’s instructions
have been received by the Company.
The PIP is offered in segregated funds only.
RSP, LIRA and non-registered contracts only. Not
applicable for Income Stage Funds of the FORLIFE Series.
Please refer to form F51-165A Dollar-Cost Averaging
for DCA Money Market Fund Numbers.
1
The transfer will be made on the transfer date
indicated above or on the next business day. If no
transfer date is indicated, said date is deemed to be
the date this request is received.
The transfer will be in effect until the first of the
following events: the end of the “Duration of the
transfer” period indicated above or the total
depletion of all the Premiums initially invested in the
Money Market Fund (DCA) indicated above. If no
duration of transfer is indicated, said duration is
automatically established at 12 months.
Same instructions as in Section 8
High Interest Savings Account: ___________ %
Investments funds: ___________ %
Fund no. % Fund no. % Fund no. %
Guaranteed Interest Fund:
Minimum amount Term Interest payment option
$500 (default) $1,000 Compound Simple
IMPORTANT: Total of percentages must be equal to 100%
Fund no. % Fund no. % Fund no. %
I request that the Company process the requested monthly transfer, starting on the day of the transfer until the depletion of all
the Premiums initially invested in the Money Market Fund (DCA) distributed over the number of months indicated below:
Date of monthly transfer:
(1 to 28)
Duration of the transfer (minimum 6 months, maximum 12 months) – Number of months:
1
INITIAL MONEY MARKET FUND – $300 MIN
Fund no.
(Specify series
and sales charge)
If front-end load,
% of premiums
% or $
Wire order no.
(Contract administrated via
Fundserv network only)
____ 5 4 5 ____
Destination funds:
Fund no. % Fund no. % Fund no. %
9- Automatic Investment Term (AIT)
12- Instructions for Automatic Withdrawal Term (AWT)
10- Dollar Cost Averaging (DCA)
Complete section 12 to indicate the Automatic
Withdrawal Term (AWT).
Method of payment
If the contract is held in a Nominee or Intermediary Account, the income payments will be issued by the Dealer.
DIRECT DEPOSIT ONLY FOR INCOME PAYMENT
Provide a blank, personal cheque bearing the Applicant’s name marked void or a duly completed written confirmation from the
financial institution.
Request to join the Periodic Income Program (PIP)
Optional
1
When investments are made in the Income Stage
Funds of the FORLIFE Series Stage Funds, the default
type of income payment is FORLIFE Income.
2
For FORLIFE income, the default amount is gross.
3
If the market value of the account at the time the
request is received is less than $5,000, the only
authorized frequency is annual.
Registration TFSA
Type of income payment
1
FORLIFE Income
1
Fixed amount $ _________________
Amount
2
Gross
2
Net
Frequency
3
Monthly (Day 1 to 28) Day: ______
Last day of each month
Annual
Date of first payment
(Mandatory)
1st to the 5th not available for the FORLIFE Income
11- Income Payment
F17A-1(21-03)
Regular PAD
Do not send first payment by cheque.
Withdrawal Agreement: Variable
Regular PAD not available for Income Stage
Funds of the FORLIFE Series.
The CID premium must not be included with the
amount enclosed with this application.
Banking information
Attach a void cheque or enclose a duly completed
written confirmation from the financial institution.
Frequency: Monthly Last day of each month Weekly Every 2 weeks
PAD amount: $__________________ Date of first PAD:
A period of three business days following reception at the service centre is required for PAD activation.
Investment instructions for the regular PAD:
Same instructions as section 8 Investment Instructions
Other – Please specify:
% %
% %
I waive the CID insurance coverage.
I would like to purchase the CID insurance coverage (complete form F1A).
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
PAD category: Personal Business (If both boxes are left unchecked, the PAD category will be deemed “Personal”.)
Transit: Institution: Bank account no.:
Name of account owner(s): ____________________________________________________________________________
– By signing below, I(we), the bank account owner(s), confirm I have read, understand and agree to the information and
provisions of the PAD Agreement in this Application.
– For a joint account, all required signatories must sign this PAD Agreement.
– For a Company, the PAD statement must be signed by an authorized signatory; attach a copy of the Company’s
resolution stipulating the authorized signatories
X ___________________________________________ X ���������������������������������������������
Bank account owner’s signature Joint account owner’s signature (if required)
Date:
One-time PAD Date of one time PAD:
Immediately
Investment instructions for the one time PAD:
Same instructions as section 8 Investment Instructions
Other – Please specify:
% %
% %
13- Pre-Authorized Debit (PAD)
14- Contribution in the Event of the Insured’s Disability (CID)
16- Special Instructions
Documents and communications regarding all of my contracts with iA Financial Group will be sent to me in electronic format
and I can consult them in My Client Space*. Documents that are currently only available in paper format will continue to be sent
via regular mail. (Read the “Electronic communications consent” section for more information.)
Once a new document or communication becomes available, I will receive a notification by email at the address I provided in the
Holder/Annuitant section.
* You can register for My Client Space on our website at ia.ca.
To be completed only if you wish to receive your
documents by regular mail.
I want to receive the below documents and communications by regular mail:
Tax documents (receipts and slips)
Other documents and communications (statements, letters, confirmations, notices, follow-ups, etc.)
15- Preferences for receiving documents
F17A-1(21-03)
The Holder must read, consent to and sign this section.
Electronic Investor Profile
Signatures
I, the Holder, hereby:
– declare that all statements and answers made by me in this application are fully complete and true;
– acknowledge that the provisions herein are an integral part of the Contract;
– confirm that I have requested that this application be drafted in the English language only. Par les présentes, je confirme avoir
demandé que la présente proposition soit rédigée en anglais uniquement;
– consent to the collection, use and disclosure of my personal information by the Company in the ways and for the purposes
identified in the “File and Personal Information” section of the Contract;
– acknowledge receipt of the IAG Savings and Retirement Plan Contract, the IAG Savings and Retirement Plan Information
Folder describing the key features of the Contract and the Fund Facts booklet; and
– confirm that I have read, understand and agree to the Contractual Declarations in this Application (and the PAD Agreement,
if applicable).
By signing below, I, the life insurance agent, confirm the following:
– that I have examined original, valid, government-issued identification documentation for the Holder and validated his/her date of
birth;
– that I have verified the identity of the bank account owner/joint owner (if any);
– that I have witnessed all signatures;
– that I have provided to the Holder a disclosure statement which discloses, among others
•
the company or companies I represent and my relationship with them;
•
that I receive compensation for the sale of life insurance and savings products such as commissions, bonuses, invitations to
conferences or other incentives; and
•
my confirmation that I do not have a conflict of interest.
– that I have all the necessary licences, certificates and knowledge (see ia.ca/products-advisors) to submit this application and
provide customer service;
If the Contract is held in a Nominee or Intermediary Account, I hereby:
– confirm to be the duly authorized agent of the Nominee or Intermediary;
– confirm that, if the Contract is issued to be held in a Registered Nominee or Intermediary Account, the Nominee or Intermediary is
the duly authorized agent of the trustee of the Registered Nominee or Intermediary Account and that this Contract is an authorized
investment for the Registered Nominee or Intermediary Account; and
– declare any conflicts of interest that I may have with respect to this transaction.
X ___________________________________________ Date:
Mandatory Life Insurance Agent/ Witness signature
Industrial Alliance Insurance and Financial Services Inc. authorized representatives’ signatures:
If Fund Units are to be credited to this Contract and if my Investor Profile form is not attached to the present application, I confirm
having completed electronic profile no.
and profile no. with my life
insurance agent.
X
___________________________________________ X ���������������������������������������������
Holder/Annuitant’s signature Signature of an authorized signatory for the Nominee
or the Intermediary (if applicable)
Signed at ___________________________________ this________ day of _____________________________20
Request for registration
Not applicable if the Contract is held in a Nominee
or an Intermediary Account.
Limited Trading Authorization
Should only be completed if the same parties have
already signed a Limited Trading Authorization for
an existing contract.
I hereby request that the Company file an election to register this Contract as a Tax-Free Savings Account (TFSA) under the Income
Tax Act (Canada) and any applicable provincial legislation.
I hereby declare that I have already signed a Limited Trading Authorization (“LTA”) for existing contract no.
authorizing the life insurance agent acting in this Application to provide written instructions to the Company on my behalf. I request
that the LTA which applies to my existing contract also apply to the Contract issued with this Application
17- Statement/Signature
18- Agent’s Disclosure
19- Issuer Signature
____________________________________________
Denis Ricard
President and Chief Executive Officer
____________________________________________
Jennifer Dibblee
Corporate Secretary
F17A-1(21-03)
CONTRACTUAL DECLARATIONS
I, the Holder, hereby:
– declare that the written and/or electronic information provided with respect to the Application for this product is complete and accurate and is the basis for the issuance of this Contract;
– understand that I should contact my life insurance agent if notice of confirmation has not been received within fifteen (15) days of paying a Premium;
– give the Company the right to correct any errors or omissions on this Application through an amendment letter;
– understand that this Application and the conditions thereof form an integral part of the Contract between the Company and me;
– declare that I have been advised by my life insurance agent to invest in the Funds selected and that I have received all of the information required from my agent regarding these Funds;
– understand that iA Financial Group, its affiliates and their agents can access information about me in order to know me better, better meet my needs and offer the best possible
service and client experience. (If you do not wish to allow this access, please contact 1-888-788-6890.)
PRE-AUTHORIZED DEBIT (PAD) AGREEMENT
In this PAD Agreement, each account owner is referred to as “I” and makes the following statements in respect to himself or herself:
– I authorize iA Financial Group and the financial institution designated (or any other financial institution I may authorize at any time) to begin deductions as per my instructions for
regular recurring payments and/or one-time payments from time to time, if applicable, for payment of all premiums, deposits, instalments and charges arising from the loan
agreement mentioned herein;
– Regular payments will be debited by the date and/or at the frequency I have chosen, whereas one-time payments from time to time can be debited from my account on any date.
Regular and/or one-time payments will be debited in accordance with the banking information provided in this application;
– I agree that, for the purpose of this PAD Agreement, all PADs from my account will be treated either as Personal or Business* depending on the choice I have made in section 13 of
this application;
– I waive the right to receive pre-notification of an increase or decrease in the amount to be debited or a change in the date and/or frequency of these payments;
– I agree that iA Financial Group is not required to provide me with written notice of a change in a PAD amount that is made as a result of my request;
– If a PAD is dishonoured for any reason such as, but not limited to, insufficient funds (“NSF”), stop payment or account closed, iA Financial Group is authorized to re-submit the payment.
Any charges incurred by iA Financial Group as a result of a dishonoured PAD will be charged within the Contract in accordance with the most recent PAD instructions;
– I can cancel or modify this PAD Agreement at any time, subject to providing iA Financial Group thirty (30) days’ notice in writing. To obtain a cancellation form or for more
information on my right to cancel the PAD Agreement, I may contact my financial institution or visit www.payments.ca regarding Rule H1 – Pre-authorized debits (PADs);
– Any cancellation of this agreement will not affect my insurance contract(s) and/or contract(s) for financial services, so long as payment is provided by an alternate method;
– iA Financial Group cannot assign this PAD Agreement without providing, any time prior to the next PAD, written notice to me of the assignment.
– I have certain recourse rights if any PAD does not comply with this PAD Agreement. For example, I have the right to receive reimbursement for any PAD that is not authorized or is not
consistent with this PAD Agreement. To obtain more information on my recourse rights, I should contact my financial institution or visit www.payments.ca regarding Rule H1 – Pre-authorized
debits (PADs);
– Before iA Financial Group debits the first PAD payment, it must receive all required documents, duly completed, and be allowed a reasonable period of time to complete its
administrative processes.
* Business PAD means a PAD for the payment of goods or services related to a business or commercial activity of the payor.
F17A-1(21-03)
Customer Service Contact Information – Individual Savings and Retirement:
Telephone number: 1-844-4iA-INFO (1-844-442-4636) Information: savings@ia.ca
Quebec City:
1080 Grande Allée West
PO Box 1907, Station Terminus
Quebec City, QC G1K 7M3
Fax: 1-855-685-5161
Toronto:
522 University Avenue
Suite 400
Toronto, ON M5G 1Y7
Fax: 1-800-810-0197
Vancouver:
400–988 Broadway W
PO Box 5900
Vancouver, BC V6B 5H6
Fax: 1-833-832-7474
F17A-1
Application
ia.ca
About iA Financial Group
Founded in 1892, iA Financial Group
offers life and health insurance
products, mutual and segregated funds,
savings and retirement plans, RRSPs,
securities, auto and home insurance,
mortgages and car loans and other
financial products and services for both
individuals and groups. It is one of the
four largest life and health insurance
companies in Canada and one of the
largest publicly traded companies in
the country. iA Financial Group stock is
listed on the Toronto Stock Exchange
under the ticker symbol IAG.
F17A-1(21-03) ACC
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
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Completed 21 April 2021

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