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insurance is no longer in effect.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and surrendered coverages are terminated and their insurance is no longer in effect.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.