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Head Office
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. 74 0 4
Applicant/Owner Name (first, last) Application/Policy Number
The Proceeds of Crime (Money Laundering) and Terrorist Financing Act requires the completion of this form. Advisors must make
every reasonable effort to determine if the Applicants/Owners are acting on behalf of a Third Party, and if so, certain information
must be recorded.
For the purpose of this question, a “third party” is someone other than the Owner or the Life Insured/Annuitant who will be paying
the premium or has/will have an ownership interest in this policy. Examples include a power of attorney signing on behalf of the
owner, someone other than the owner or life insured/annuitant paying premiums, or a corporation having use or access to the
policy values.
If a Third Party has been identified, indicate the type below and complete either the “Individual Third Party” or “Business / Entity
Third Party” section as applicable. The information is required to comply with Canadian legislation. In order for us to process your
application, please complete all of the provided fields.
Type of Third Party (select one and attach any applicable legal documentation)
payor trustee executor collateral/assignee attorney/power of attorney/mandatary
other (please specify):
Individual Third Party
Name of Third Party (first, middle, last): Date of Birth (dd/mm/yyyy)
Address (number, street and apartment) City or Town Province
Phone number
Postal Code Country
Relationship to Owner Occupation (job title and duties) – if not currently working, indicate former occupation
Business / Entity Third Party
Full Legal Name
(number, street and apartment) City or Town Province
Phone number Postal Code Country
Relationship to Owner Nature of principal business
Incorporation / Registration Number (if applicable) Jurisdiction / Country of Issue (if applicable)
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Political Positions (for Universal Life, Whole Life or Non-Registered Policies only)
Use this section if the payor has become a Politically Exposed Person, if a deposit is equal to or greater than $100,000, or if
you have been requested to complete this section
For the purposes of this question:
• “Payor” means the person who is making the payment(s) on the policy.
• “Close relative” means the Payors Spouse, sibling, parent, Spouses parent, child, or child’s Spouse.
• “Close associate” means an individual who is closely connected to the Payor for personal or business reasons.
• “Spouse” means the spouse or common law partner.
Does the Payor, any of the Payor’s close relatives or any of the Payor’s close associates hold, or have they ever held, any of
the positions listed below:
No Yes - indicate the position held below
Position in Canada or in another country
Note: For positions in Canada, list only the positions held in the past 5 years. For all other countries, list all such positions
that have ever been held.
Head of state or head of government (including
Governor General and Lieutenant Governor)
President of a state-owned company or bank (including
a corporation that is wholly owned by a federal or
provincial government)
Member of the executive council of government or
member of a legislature (including the Senate, House
of Commons or a provincial legislature)
Head of a government agency
Judge (in Canada only, must be a judge of an
appeal court)
Head of an international organization that is established
by the governments of countries or the head of an
institution of any such organization (indicate only if position
held in the past 5 years)
Deputy Minister (or equivalent)
Leader or President of a political party in a legislature
Ambassador or ambassador’s attaché or counsellor
Military General (or higher rank)
Mayor of a Canadian municipality (does not include
mayors in countries other than Canada)
If you answered “Yes” to the question above, complete the following information:
What is the name of the person who holds or held the
What is the title of the position held?
Position held from:
(starting year)
(ending year)
In what country was the positon held?
With what organization, government or institution was the
position held?
How is this person related to the Payor?
The person is the Payor
Close relative (relationship):
Close associate (relationship):
What is the Payor’s source of wealth (check all that apply):
Salary or Earned Income Business Income Inheritance
Property Income/ Holdings Investment Income Other
Advisor Certification
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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.
Select one of the following options:
I have made a reasonable effort to determine if a third party is acting on behalf of an owner, and have included the
applicable Third Party information in the above sections.
I was unable to determine that the Applicant/Owner is acting on behalf of a Third Party, but I have reasonable grounds
to suspect this is the case.
Did the applicant/owner indicate that the transaction was being conducted by a Third Party?
a) If “Yes, please provide details.
b) If “No, please provide reasons to suspect the Annuitant/Owner is acting on behalf of a Third Party.
Name of Advisor Signature of Advisor Date (dd/mm/yyyy) Advisor Code