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Country of origin: CANADA
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TERMINATION FOR INTERNAL REPLACEMENT
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
Policy or Coverage to be surrendered
General Information
Use this form to surrender your Equitable Life
®
policy or a coverage under your policy, and replace it with a new Equitable Life
policy or a new coverage under your policy.
We will terminate the policies and coverages that you are surrendering when we receive this completed form. Do not submit this
form to us until your new policy or new coverage is issued by Equitable Life.
To qualify for a refund of overlapping premiums we must receive this form within 30 days of the issue date of the new policy or
new coverage.
Note: if the surrender results in a policy cash value payment, it may be taxable income and a tax reporting slip issued.
Name of Policy Owner #1 (First, middle initial, last or full name or legal entity)
Name of Policy Owner #2 (First, middle initial, last or full name or legal entity)
New Policy number or existing Policy number if a new coverage Issue Date
(dd/mm/yyyy)
1609(2020/06/30) Page 1 of 2
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
CustomerService-GeneralMailbox@equitable.ca
www.equitable.ca
£ Policy Is enclosed £ Policy has been lost, misplaced or stolen
Existing Policy Number
£ Surrender Policy
£ Surrender Coverage Only - Coverage to be surrendered:
Existing Policy Number
£ Surrender Policy
£ Surrender Coverage Only - Coverage to be surrendered:
Existing Policy Number
£ Surrender Policy
£ Surrender Coverage Only - Coverage to be surrendered:
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
1609(2020/06/30) Page 2 of 2
Any money payable resulting from the surrender will be paid based on your instructions below. This payment, if any, settles all
claims and demands and releases and fully discharges Equitable Life of Canada from all liability associated with the surrendered
policies and coverages. Upon surrender, the surrendered policies and surrendered coverages are terminated and their
insurance is no longer in effect.
All owners of the policy to be surrendered or owners of the policy with coverages to be surrendered must sign this form.
By signing below you confirm that you have chosen to replace an existing policy with a new policy or replace a coverage on
your existing policy with a new coverage that Equitable Life has recently issued to you. Upon surrender, the surrendered policies
and surrendered coverages are terminated and their insurance is no longer in effect.
Policy or Coverage to be surrendered
Signatures and Authorizations
By direct deposit £ Use Banking Information on File
(only available if information on file is for the existing Policy Owner)
£ Use Void Cheque Attached
(account must be in the name of the existing Policy Owner)
By cheque £ Payable to Policy Owner
Apply Funds to Equitable £ To reduce an existing loan
Policy number: £ To pay monthly premiums for maximum of 2 months -
balance refunded to existing Policy Owner
£ To apply toward Annual Premiums - Policy Owner must submit balance
of Annual Premiums (if applicable)
£ Lump Sum Deposit (applicable to Universal Life policy only)
Signed at (City/Town) (Province)
Signature of Policy Owner #1 Date (dd/mm/yyyy)
Signature of Policy Owner #2 Date (dd/mm/yyyy)
Signature of collateral assignee Date (dd/mm/yyyy)
Signature irrevocable beneficiary (if applicable) Date (dd/mm/yyyy)
Irrevocable Beneficiaries on a policy must sign to show their consent to the surrender
TERMINATION FOR INTERNAL REPLACEMENT
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.
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Completed 17 March 2021

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