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Documenti di Professioni
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Application
Detach this page and deliver to the Proposed Insured(s) and Owner(s).
LP2577/14
Application No.
Policy No.
What type of policy are you applying for:q Individual Lifeq Joint First-to-Dieq Joint Last-to-Dieq Multiple Life Coverages
Names of all Proposed Insureds to be covered under this policy:_________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
This is a:
q Critical Illness Protection q Estate Planning q Key Person Insurance q Life Protection
q Partnership q Retirement Planning
q Other __________________________________________
First Name
Identification Document*
Middle Initial
Last Name
Issuing Jurisdiction*
*Please refer to an original, non-expired passport, birth certificate, drivers license, Canadian citizenship, age of majority or Canadian Armed Forces identification (preferably photo I.D.).
2. Date of Birth:
DDMMYYYY
Gender: q M q F
Country of birth: ____________________________ SIN: __ __ ____ __ __ __ __ __ (Optional: complete only if you are the Owner and applying for a Universal Life policy)
Former/Maiden Name:_________________________________________________________________________________________________________
3. Current address (Number and street name)
_______________________________________________________________________________________________________ Apt/Suite ____________
City ______________________________________________ Province __________________________________ Postal Code ___________________
Home telephone: ( ________ ) __________________________________ Business telephone: ( ________ ) __________________________________
4. I understand the language in which this application is written.
q Yes q No
If No, have the details of this application been fully explained to you in your preferred language and are they completely understood?
q Yes q No
Canadian Citizen
Landed Immigrant/Permanent Resident Number of years/months residing in Canada: _______ Years
Contract Worker (provide copy of work permit) Number of years/months residing in Canada: _______ Years
Other (give details of current status)
Number of years/months residing in Canada: _______ Years
_____________________________________________________________________________________________________________________
_______ Months
_______ Months
_______ Months
q Yes q No
c)
Complete only if the Proposed Insured is the Owner and applying for a Universal Life policy:
Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN).
q Yes q No
q Yes q No
q Yes q No
q Part Time
Employers address:________________________________________________________________________________________________________
Duties: ___________________________________________________ A
nnual Income $ _______________ Total Net Worth $ _______________
*FRM-LP2578/12*
**DO NOT DETACH THIS PAGE**
LP2577/14
First Name
Identification Document*
Middle Initial
Last Name
Issuing Jurisdiction*
*Please refer to an original, non-expired passport, birth certificate, drivers license, Canadian citizenship, age of majority or Canadian Armed Forces identification (preferably photo I.D.).
8. Date of Birth:
DDMMYYYY
Gender: q M q F
Country of birth: ____________________________ SIN: __ __ ____ __ __ __ __ __ (Optional: complete only if you are the Owner and applying for a Universal Life policy)
Former/Maiden Name:_________________________________________________________________________________________________________
9. Current address (Number and street name)
_______________________________________________________________________________________________________ Apt/Suite ____________
City ______________________________________________ Province __________________________________ Postal Code ___________________
Home telephone: ( ________ ) __________________________________ Business telephone: ( ________ ) __________________________________
10. I understand the language in which this application is written.
q Yes q No
If No, have the details of this application been fully explained to you in your preferred language and are they completely understood?
q Yes q No
Canadian Citizen
Landed Immigrant/Permanent Resident Number of years/months residing in Canada: _______ Years
Contract Worker (provide copy of work permit) Number of years/months residing in Canada: _______ Years
Other (give details of current status)
Number of years/months residing in Canada: _______ Years
_____________________________________________________________________________________________________________________
_______ Months
_______ Months
_______ Months
q Yes q No
c)
Complete only if the Proposed Insured is the Owner and applying for a Universal Life policy:
Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN).
q Yes q No
q Yes q No
q Yes q No
q Part Time
Employers address:_______________________________________________________________________________________________________
Duties: _____________________________________________________ A
nnual Income $ _____________ Total Net Worth $ ______________
Application No.
q English q Franais
b) The Owner will be (all of) the adult Proposed Insured(s) unless indicated otherwise below:
q Proposed Insured 1
q Proposed Insured 2
OWNER 1
Legal Name (first, middle initial, last and/or Legal company/entity name)
Identification Document*
Issuing Jurisdiction*
Date of Birth (DD/MM/YYYY) SIN (Optional: complete only if you are applying for a Universal Life policy)
Current Address (Number and street name) Apt/Suite
City
Province
Postal code
Phone Number
Complete only if you are applying for a Universal Life policy:
Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN).
q Yes q No
OWNER 2
Legal Name (first, middle initial, last and/or Legal company/entity name)
Identification Document*
Issuing Jurisdiction*
Date of Birth (DD/MM/YYYY) SIN (Optional: Complete only if you are applying for a Universal Life policy)
Current Address (Number and street name) Apt/Suite
City
Province
Postal code
Phone Number
Complete only if you are applying for a Universal Life policy:
Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN).
q Yes q No
*Please refer to an original, non-expired passport, birth certificate, drivers license, Canadian citizenship, age of majority or Canadian Armed Forces identification (preferably photo I.D.).
c)
Multiple Owners
i) Canadian Provinces (excluding Qubec) Where there are multiple Owners, the policy will be issued to all Owners with Right of
Survivorship should an Owner die while the policy is in effect, the deceased Owners interest automatically transfers to the surviving Owner(s)
unless the option Tenants in Common is selected below.
q Tenants in Common (undivided co-ownership) should an Owner die while the policy is in effect, the deceased Owners interest will
transfer to his/her estate unless a contingent Owner has been named for such Owner.
ii) Province of Qubec only Ownership must be Tenants in Common. Tenants in Common (undivided co-ownership) means that should an
Owner die while the policy is in effect, the deceased Owners interest will transfer to his/her estate. Please name one another as contingent
owners if Right of Survivorship is desired.
Please provide relationship of each Owner to all other Owners: ______________________________________________________________________
d) Mailing Address (Where there are multiple Owners, all notices and statements will be mailed to Owner 1 unless another address is indicated)
City
Province
Postal code
e) Contingent Owner
For Life and Critical Illness Insurance Policies, if you wish to have your ownership interest transferred to another person in the event of your
death, complete this section. If Joint Ownership is Right of Survivorship, the ownership interest will only be transferred to the contingent owner
listed for the last surviving Owner upon that Owners death. If Joint Ownership is Tenants in Common and no contingent owner is named, the
deceased Owners interest will transfer to his/her estate.
For Critical Illness Policy a contingent owner can be designated in Alberta, British Columbia, Manitoba, Ontario and Qubec. If no contingent
owner is named, upon death of the policy owner, ownership will be transferred to the policy owners estate.
Name of Owner
Name of Owner
Relationship to Owner
Relationship to Owner
OWNER 1
OWNER 2
YES NO
q q
ii) Do you, the Proposed Owner(s), or any person to whom you are related by blood or marriage (including your
common-law partner), hold, or have held in the past, any of the following positions in a country other than Canada:
head of state, member of the executive council of government or member of the legislature, deputy minister
(or equivalent), ambassador or ambassadors attach or counsellor, military general (or higher rank), president of
state-owned company or bank, judge or leader or president of a political party in a legislature?. . . . . . . . . . . . . . . . q q
q q
Each Owner who answers Yes to f) ii) must complete the Politically Exposed Foreign Person Form (IP-LP1165) and submit it along with the application.
g) Consent to Receive E-mails to be Completed by the Owner(s)
Canadas Anti-Spam Legislation regulates the distribution of commercial electronic messages (e.g. e-mails) to consumers. To comply with this
law, Transamerica Life Canada is required to obtain your consent for the purposes of sending you commercial electronic messages regarding
your policy, product information and marketing material.
By providing your e-mail address below, you are consenting to receiving commercial electronic messages as outlined above from
Transamerica Life Canada.
You may withdraw your consent at any time by contacting us at Transamerica Life Canada as follows:
Application No.
q Primary
Check one:
q Revocable q Irrevocable
Share %
Share %
Share %
Share %
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Qubec):
q Contingent
q Primary
Share %
Share %
q Contingent
q Primary
q Contingent
If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Qubec):
q Primary
Check one:
q Revocable q Irrevocable
Share %
Share %
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
q Contingent
If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Qubec):
Application No.
q Primary
Check one:
q Revocable q Irrevocable
Share %
Share %
Share %
Share %
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Qubec):
q Contingent
q Primary
Share %
Share %
q Contingent
q Primary
q Contingent
If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Qubec):
q Primary
Check one:
q Revocable q Irrevocable
Share %
Share %
q Contingent
q Primary
Check one:
q Revocable q Irrevocable
q Contingent
If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Qubec):
Application No.
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
a) Has any Application, reinstatement, modification for Life, Critical Illness, Long Term Care or Disability Insurance
ever been rated, declined, postponed, cancelled, rescinded or modified in any way? . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
b) i) Is this Insurance intended to replace, or will it cause a change, in any existing Life or Critical Illness Insurance
with this or any other Company? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
q q
q q
q q
q q
ii)
If the intent of this application for insurance is to replace an existing Transamerica policy/coverage,
does the Owner instruct Transamerica to cancel that policy/coverage on the effective date of the
policy being applied for? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Yes for Life, attach the completed Replacement/Comparison Disclosure Forms, LIRD (where applicable).
Note: Only the policy owner has the right to cancel the existing policy/coverage. If there is a change in
ownership, you must submit a Transfer of Ownership or Letter of Direction signed by the original owner. Its
the policyowners responsibility to continue to pay premiums on the original policy while the new application is
being assessed to avoid a lapse in coverage.
c) Do you have any of the following insurance in force or pending: Life Insurance, Critical Illness, Disability,
Long Term Care? If Yes, complete the table in Question 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Yes to questions a), b) or c), provide additional information in the Remarks section.
Amount of
Insurance
Company
Type of
Insurance Plan:
Life
CI
DI
Personal/
Business:
LTC
Issue
Year
In Force
Pending
Changed Replaced
q q q q q q
q q q q q q
q q q q q q
q q q q q q
q q q q q q
q q q q q q
PROPOSED INSURED #
DETAILS
FINANCIAL INFORMATION
Personal where the face amount is $1,000,000 or more, complete Question 18.
Business w
here the Insurance is for business purposes, the Owner or beneficiary is a corporation, non-corporate entity or trust,
complete Question 19.
18. PERSONAL
a) Financial Details
PROPOSED
INSURED 1
PROPOSED
INSURED 2
Owner
(where individual Owner is not a
Proposed Insured)
19. BUSINESS
a) Name of Business:
____________________________________________
Liabilities
PROPOSED INSURED 1
Net Worth
PROPOSED INSURED 2
Name, Title/Occupation
Financial Statement
Letter of Explanation
q enclosed
q enclosed
q to follow
q to follow
Additional Comments:
10
% of Business
Ownership
Application No.
Identification Identification
Document*
Document Number*
Issuing Jurisdiction*
*Please refer to an original non-expired passport, birth certificate, drivers license, Canadian citizenship, age of majority or Canadian Armed Forces
identification (preferably photo ID).
2. Corporation Please provide Corporate information including corporate structure document. For more information on supporting documents
required refer to the Summary Table.
Official Corporate Name
Address
Place of Federal or Provincial Incorporation
Names of all Directors of Corporation (If necessary, attach listing of all directors)
Occupation
_________________________________________________________________________________________ _________________________________
_________________________________________________________________________________________ _________________________________
_________________________________________________________________________________________ _________________________________
_________________________________________________________________________________________ _________________________________
_________________________________________________________________________________________ _________________________________
Names of all individuals who directly or indirectly own or control 25% or more of the shares of the Corporation.
Name of Individual
Occupation
Address
______________________________________
_____________________________ ____________________________________________________
______________________________________
_____________________________ ____________________________________________________
______________________________________
_____________________________ ____________________________________________________
______________________________________
_____________________________ ____________________________________________________
11
3. Non-Corporate Entity Please provide Non-Corporate Entity information. For more information on supporting documents required refer to
the Summary Table.
Official Name of Entity and Address
Place of Issue Registration Number
Type of Document/Entity
Names of all individuals who directly or indirectly own or control 25% or more of the Non-Corporate Entity.
Name of Individual
Occupation
Address
______________________________________
_____________________________ ____________________________________________________
______________________________________
_____________________________ ____________________________________________________
______________________________________
_____________________________ ____________________________________________________
______________________________________
_____________________________ ____________________________________________________
4. Trust Please provide Trust information. For more information on supporting documents required refer to the Summary Table on the next page.
Name of person who created the Trust (Settlor)
Address
___________________________________________________
_____________________________________________________________________
___________________________________________________
_____________________________________________________________________
Name of Trustee
Address
___________________________________________________
_____________________________________________________________________
___________________________________________________
_____________________________________________________________________
Name of Beneficiary
Address
___________________________________________________
_____________________________________________________________________
___________________________________________________
_____________________________________________________________________
12
Application No.
SUMMARY TABLE
Type of account
Corporation
(Complete section 1 and 2)
Names and addresses of all individuals who directly or indirectly own or control 25% or more of the
shares of the corporation.
(If this information cannot be obtained, we must keep a record explaining why beneficial ownership could
not be determined).
Certificate of Incumbency
International Tax Classification for an Entity Form (IP-LP1601)
Name and address of the entity
Name and address of all individuals who directly or indirectly own or control 25% or more of the entity.
(If this information cannot be obtained, we need to keep a record explaining why beneficial ownership
could not be determined).
Non-Corporate Entity
Certificate of Incumbency
Trust
13
q 10 Year Rider
q 20 Year Rider
q 10 Year
q 20 Year
Benefit Riders
Face Amount
$__________________
q Childrens Insurance
q Accidental Death & Dismemberment
q Waiver of Premium
$__________________
$__________________
Benefit
q Term 10 CI 4 conditions
q Term 20 CI 4 conditions
q Term to age 65 CI 4 conditions
q Term 10 CI 25 conditions
q Term 20 CI 25 conditions
q Term to age 65 CI 25 conditions
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
*The Critical Illness Benefit applied for cannot exceed the total life insurance face amount applied for.
When applying for a Critical Illness Protection policy, complete this section.
Riders
q Term 10 CI 4 conditions
q Term 20 CI 4 conditions
q Term to age 65 CI 4 conditions
q Term 10 CI 25 conditions
q Term 20 CI 25 conditions
q Term to age 65 CI 25 conditions
q Waiver of Premium
q Payor Waiver of Premium*
Benefit
q Term 10 CI 4 conditions
q Term 20 CI 4 conditions
q Term to age 65 CI 4 conditions
q Term 10 CI 25 conditions
q Term 20 CI 25 conditions
q Term to age 65 CI 25 conditions
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
NOTE: Early Detection Benefit and Childhood Critical Illness Covered Conditions are only available with the 25 conditions Critical Illness Protection products.
14
Application No.
q 10 Year Rider
q 20 Year Rider
q 10 Year
q 20 Year
Benefit Riders
Face Amount
$__________________
q Childrens Insurance
q Accidental Death & Dismemberment
q Waiver of Premium
$__________________
$__________________
Benefit
q Term 10 CI 4 conditions
q Term 20 CI 4 conditions
q Term to age 65 CI 4 conditions
q Term 10 CI 25 conditions
q Term 20 CI 25 conditions
q Term to age 65 CI 25 conditions
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
*The Critical Illness Benefit applied for cannot exceed the total life insurance face amount applied for.
When applying for a Critical Illness Protection policy, complete this section.
Riders
q Term 10 CI 4 conditions
q Term 20 CI 4 conditions
q Term to age 65 CI 4 conditions
q Term 10 CI 25 conditions
q Term 20 CI 25 conditions
q Term to age 65 CI 25 conditions
q Waiver of Premium
q Payor Waiver of Premium*
Benefit
q Term 10 CI 4 conditions
q Term 20 CI 4 conditions
q Term to age 65 CI 4 conditions
q Term 10 CI 25 conditions
q Term 20 CI 25 conditions
q Term to age 65 CI 25 conditions
$__________________
$__________________
$__________________
$__________________
$__________________
$__________________
NOTE: Early Detection Benefit and Childhood Critical Illness Covered Conditions are only available with the 25 conditions Critical Illness Protection products.
15
q PROPOSED INSURED 2
PROPOSED INSURED 1
b) q Alternate/Optional Policy:
Plan:__________________________________________________________
c) q Additional Policy:
Plan:__________________________________________________________
PROPOSED INSURED 2
d) q Alternate/Optional Policy:
Plan:__________________________________________________________
e) q Additional Policy:
Plan:__________________________________________________________
(attach cheque, pre-printed with the Payors name and marked VOID, or a bank Letter of Direction.)
b) Future Premiums/Deposits to be paid by:
q Monthly
q Quarterly
Direct Bill:
q Annual
q Semi-Annual
q Quarterly
16
Application No.
INSTRUCTIONS
If the Proposed Insured is 16 years of age or greater, complete the Adult Section Questions 24 41.
If the Proposed Insured is less than 16 years of age, complete the Juvenile Section Questions 42 58.
If a Child Rider Benefit is requested, complete the Child Insurance Rider Section Questions 59 67.
PERSONAL HISTORY
(To be completed if the Proposed Insured is 16 years of age or greater.)
24. Have you smoked or used any of the products listed in the table below:
a) in the last 12 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b) in the last 24 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
q q
q q
Quantity
Cigarettes
q Day
q Day
q Day
q Day
q Day
q Day
q Day
q Day
q Day
q Day
q Day
q Day
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
(MM / YYYY)
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
Cigarettes
Cigarillos (little cigars)
Electronic cigarette
Pipe
Shisha/hookah (water pipe)
Cigars
PROPOSED Chewing tobacco
INSURED 2: Betal nuts
Snuff
Nicotine patch
Nicorette chewing gum
Marijuana/Hashish (Joints)
Any other smoking cessation products, or
used tobacco in any other form
Frequency
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Week
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Month
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Year
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
q Single Use
17
25. Within the next 12 months do you expect to travel outside Canada and the United States? . . . . . . . . . . . . . . . . . . . .
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
If Yes, provide details: countries, cities, purpose of travel, length of stay and expected number of trips per year.
If you require more space, please use the Remarks section or complete the Foreign Travel Questionnaire (UW-FTQ399).
City and Country
Purpose of Travel
Length of Stay
# of times per
Year
PROPOSED
INSURED 1:
PROPOSED
INSURED 2:
a) In the last 12 months, have you piloted an aircraft other than with a commercial/major airline carrier or
do you intend to do so in the next 12 months?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
q q
q q
b) In the last 12 months, have you engaged in any hazardous sports (including, but not limited to, motorized vehicle
racing, scuba or sky diving, parachuting, hang-gliding and mountain climbing) , or do you intend to do so
in the next 12 months?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c) In the last 10 years, have you had your drivers license suspended or revoked? . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
d) In the last 2 years, have you refused to provide a breathalyzer sample, and/or have you had 2 or more highway
traffic violations?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
If Yes, provide drivers license number and provide reasons(s), date(s), type(s) of offence(s) in the
Remarks section.
e) In the last 10 years, have you ever been convicted of any criminal offence or fraudulent financial charges or do you
have any charges pending? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
f) In the last 5 years, have you ever been bankrupt and not received a discharge, or are you currently involved in a
bankruptcy proceeding?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PROPOSED INSURED #
DETAILS
18
q q
q q
q q
q q
Application No.
HEALTH HISTORY (To be completed if the Proposed Insured is 16 years of age or greater.)
PROPOSED INSURED 1
27. Name of the Proposed Insured:
_______________________________________________________________________________________________________________________
q ft/in
q lbs.
Height: __________________________________________________ q cm
Weight: _________________________________________ q kg
28. Do you have a family doctor or clinic that you use regularly?
Gain: ________________________________________________
q Yes q No
If Yes, give the name of the doctor and the name of the clinic.
Name of Doctor/Clinic:____________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________________
Phone: _________________________________________________________________________________________________________________
Results: ________________________________________________________________________________________________________________
Treatment: ______________________________________________________________________________________________________________
q Yes q No
Details: _________________________________________________________________________________________________________________
PROPOSED INSURED 2
29. Name of the Proposed Insured:
_______________________________________________________________________________________________________________________
q ft/in
q lbs.
Height: __________________________________________________ q cm
Weight: _________________________________________ q kg
30. Do you have a family doctor or clinic that you use regularly?
Gain: ________________________________________________
q Yes q No
If Yes, give the name of the doctor and the name of the clinic.
Name of Doctor/Clinic:____________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________________
Phone: _________________________________________________________________________________________________________________
Results: ________________________________________________________________________________________________________________
Treatment: ______________________________________________________________________________________________________________
q Yes q No
Details: _________________________________________________________________________________________________________________
**DO NOT DETACH THIS PAGE**
19
FAMILY HISTORY
31. Has any family member (whether living or deceased) ever suffered from, or is any family member suffering from,
high blood pressure, heart disease, stroke, cancer (specify type), diabetes, polycystic kidney disease, mental illness,
Huntingtons Chorea, Amyotrophic Lateral Sclerosis (ALS or Lou Gehrigs Disease), motor neuron disease, multiple
sclerosis, Alzheimers Disease, Parkinsons disease or any other hereditary disease? . . . . . . . . . . . . . . . . . . . . . . . .
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
PROPOSED INSURED 1
Family Member
Condition
Age at Onset
Age if Living
Age at Death
Cause of Death
Condition
Age at Onset
Age if Living
Age at Death
Cause of Death
Father
Mother
Brother
Brother
Brother
Sister
Sister
Sister
PROPOSED INSURED 2
Family Member
Father
Mother
Brother
Brother
Brother
Sister
Sister
Sister
20
Application No.
HEALTH HISTORY
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
32. In the last 5 years, have you consulted any medical advisors other than as identified on Page 19? . . . . . . . . . . . . . .
If Yes, provide name and address in the Remarks section.
q q
q q
33. Are you now being observed or treated by any medical advisor, or taking any medication other than as identified
on Page 19? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
q q
q q
q q
q q
Gastrointestinal System:
c) the digestive organs, such as ulcer, bleeding, recurrent indigestion, persistent diarrhea, ulcerative colitis, Crohns
disease, hepatitis, hepatitis carrier or jaundice, cirrhosis of the liver or any other disease or disorder of the mouth,
esophagus, stomach, liver, pancreas, intestines or rectum?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
q q
q q
q q
q q
For any Yes answers, provide additional information in the Remarks section.
34. Have you ever had, or ever been told you had, or received treatment or advice for:
q q
q q
q q
q q
q q
q q
Immune System:
i) the immune system, such as an immune deficiency syndrome, AIDS or test results indicating exposure to the virus
causing AIDS (HIV), lupus, scleroderma or any other disease or disorder of the immune system?. . . . . . . . . . . . .
q q
q q
q q
q q
35. a) Have you ever had, or ever been told you had, any disease, condition, abnormality or hereditary disorder not
already mentioned? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
b) Have you ever applied for or received a pension, disability benefit or any compensation because of an illness,injury
or surgery not yet completed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36. Do you have any reason to believe that you are not in good health, or are you aware of any symptoms for which you
have not yet sought treatment or consultation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
**DO NOT DETACH THIS PAGE**
21
q q
q q
q q
q q
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
PROPOSED
INSURED 1:
PROPOSED
INSURED 2:
Number/Amount
Frequency Per
Beer
Bottles per
q Day
q Week
q Month
q Year
q Occasionally/Socially
Wine
Glasses per
q Day
q Week
q Month
q Year
q Occasionally/Socially
q oz q ml per q Day
q Week
q Month
q Year
q Occasionally/Socially
Liquor
Beer
Bottles per
q Day
q Week
q Month
q Year
q Occasionally/Socially
Wine
Glasses per
q Day
q Week
q Month
q Year
q Occasionally/Socially
q oz q ml per q Day
q Week
q Month
q Year
q Occasionally/Socially
Liquor
41. Have you ever decided to or been advised to decrease consumption of alcohol or drugs, or ever received, or been
advised to receive, counselling or treatment for drug dependency or the use/abuse of alcohol or chemicals? . . . . . .
PROPOSED
INSURED 1
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
If Yes, provide details in the Remarks section, including date of last use.
Remarks Details of any Yes answers.
If applicable, attach the appropriate completed questionnaire(s).
QUESTION #
PROPOSED INSURED #
DETAILS (provide dates, diagnosis, results of investigations, names of medical advisors, medical facilities and treatment)
22
Application No.
PROPOSED INSURED #
DETAILS (provide dates, diagnosis, results of investigations, names of medical advisors, medical facilities and treatment)
23
INSTRUCTIONS
If the Proposed Insured is 16 years of age or greater, complete the Adult Section Questions 24 41.
If the Proposed Insured is less than 16 years of age, complete the Juvenile Section Questions 42 58.
If a Child Rider Benefit is requested, complete the Child Insurance Rider Section Questions 59 67.
PERSONAL HISTORY
(If the Proposed Insured is less than 16 years of age, complete questions 42 to 58.)
42. PROPOSED INSURED 1 Note: Either a parent or legal guardian of the Proposed Insured must sign this application, as well as the Owner.
Relationship of Owner to child:
Does this child live with the Owner? If No, who does this child live with? Relationship
q Parent
q Legal Guardian
q Grandparent
q Yes q No
q Yes q No
If Yes, do the siblings have any Life or Critical Illness Insurance in force or pending?
q Yes q No
If Yes, what is the amount of Life or Critical Illness Insurance on each sibling?
1. $
2. $
3. $
If No, provide details:
4. $
43. PROPOSED INSURED 2 Note: Either a parent or legal guardian of the Proposed Insured must sign this application, as well as the Owner.
Relationship of Owner to child:
Does this child live with the Owner? If No, who does this child live with? Relationship
q Parent
q Legal Guardian
q Grandparent
q Yes q No
q Yes q No
If Yes, do the siblings have any Life or Critical Illness Insurance in force or pending?
q Yes q No
If Yes, what is the amount of Life or Critical Illness Insurance on each sibling?
1. $
2. $
3. $
If No, provide details:
24
4. $
Application No.
44. Within the next 12 months, does the child expect to travel outside Canada and the United States? . . . . . . . . . . . . .
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
If Yes, provide details: countries, cities, purpose of travel, length of stay and expected number of trips per year.
If you require more space, please use the Remarks section or complete the Foreign Travel Questionnaire (UW-FTQ399).
City and Country
Purpose of Travel
Length of Stay
PROPOSED
INSURED 1:
PROPOSED
INSURED 2:
a) In the last 24 months, has the child engaged in any hazardous sports or extreme sports including, but not limited
to, out of bound skiing, base jumping, bungee jumping, ski jumping, sky diving, sky surfing, cliff diving, scuba
diving, motorized racing, mountain climbing, etc.? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PROPOSED INSURED #
DETAILS
25
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
q q
q q
47. Do you have a family doctor or clinic that the child regularly uses?
Gain: ________________________________________________
q Yes q No
If Yes, give the name of the doctor and the name of the clinic.
Name of Doctor/Clinic:____________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________________
Phone: _________________________________________________________________________________________________________________
Results: ________________________________________________________________________________________________________________
Treatment: ______________________________________________________________________________________________________________
q Yes q No
Details: _________________________________________________________________________________________________________________
PROPOSED INSURED 2
48. Name of the Proposed Insured:
_______________________________________________________________________________________________________________________
q ft/in
q lbs.
Height: __________________________________________________ q cm
Weight: _________________________________________ q kg
49. Do you have a family doctor or clinic that the child regularly uses?
Gain: ________________________________________________
q Yes q No
If Yes, give the name of the doctor and the name of the clinic.
Name of Doctor/Clinic:____________________________________________________________________________________________________
Address: _______________________________________________________________________________________________________________
Phone: _________________________________________________________________________________________________________________
Results: ________________________________________________________________________________________________________________
Treatment: ______________________________________________________________________________________________________________
q Yes q No
Details: _________________________________________________________________________________________________________________
**DO NOT DETACH THIS PAGE**
26
Application No.
WHERE A PARAMEDICAL IS REQUIRED, THE PROPOSED INSURED(S) LESS THAN 16 YEARS OF AGE DO(ES) NOT NEED TO
COMPLETE QUESTIONS 50 to 58.
FAMILY HISTORY
50. Has any family member (whether living or deceased) ever suffered from, or is any family member suffering from,
high blood pressure, heart disease, stroke, cancer (specify type), diabetes, polycystic kidney disease, mental illness,
Huntingtons Chorea, Amyotrophic Lateral Sclerosis (ALS or Lou Gehrigs Disease), motor neuron disease, multiple
sclerosis, Alzheimers Disease, Parkinsons disease or any other hereditary disease? . . . . . . . . . . . . . . . . . . . . . . . .
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
PROPOSED INSURED 1
Family Member
Condition
Age at Onset
Age if Living
Age at Death
Cause of Death
Condition
Age at Onset
Age if Living
Age at Death
Cause of Death
Father
Mother
Brother
Brother
Brother
Sister
Sister
Sister
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
PROPOSED INSURED 2
Family Member
Father
Mother
Brother
Brother
Brother
Sister
Sister
Sister
Maternal Grandfather
Maternal Grandmother
Paternal Grandfather
Paternal Grandmother
**DO NOT DETACH THIS PAGE**
27
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
51. In the last 5 years, has the child consulted any medical advisors other than as identified on Page 26? . . . . . . . . . . . . .
If Yes, provide name and address in the Remarks section.
q q
q q
52. Is the child currently being observed or treated by any medical advisor, or taking any medication other than as
identified on Page 26? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
53. Has the child ever had, or ever been told he or she had, or received treatment or advice for:
Heart and Circulatory System:
a) congenital heart disorder, heart murmur or any other heart or circulatory disorder?. . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
q q
q q
Gastrointestinal System:
c) gastrointestinal problem, including persistent or chronic diarrhea, inflammatory bowel disease, celiac disease,
hepatitis, including hepatitis carrier, jaundice or any other liver or pancreatic disease? . . . . . . . . . . . . . . . . . . . . .
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
Immune System:
i) AIDS or any other disorder of the immune system, or tested positive for exposure to the virus causing
AIDS (HIV)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
q q
54. a) Has the child had, or ever been told he or she had, any disease, condition, abnormality or hereditary disorder not
already mentioned? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b) Has the child ever applied for, or received a pension, disability benefit or any compensation because of an illness,
injury or surgery not yet completed?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c) If the child is less than 2 years old, was the child born prematurely?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
55. Do you have any reason to believe that the child is not in good health, or are you aware of any symptoms for which
the child has not received treatment or consultation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
56. a) In the last 5 years, has the child ever had or been recommended to have a Computer Tomography Scan
(CTScan) or Magnetic Resonance Imaging (MRI) and/or any other diagnostic testing not mentioned above? . . . .
b) In the last 5 years, has the child ever had an electrocardiogram, x-ray or other diagnostic test?. . . . . . . . . . . . . .
57. Has the child ever used any sedative, stimulant, tranquilizer, hallucinogen, narcotic or other drug including marijuana,
cocaine, amphetamines, barbiturates, etc., not prescribed by a physician? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
58. Has the child ever received treatment, been advised to received treatment or reduce consumption, or joined an
organization because of the use of alcohol or drugs? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If Yes, provide details in the Remarks section on the following page, including date of last use.
28
Application No.
PROPOSED INSURED #
DETAILS (provide dates, diagnosis, results of investigations, names of medical advisors, medical facilities and treatment)
29
Height
q ft/in
q cm
Weight
q lbs
q kg
Height
q ft/in
q cm
Weight
q lbs
q kg
Height
q ft/in
q cm
Weight
q lbs
q kg
Height
q ft/in
q cm
Weight
q lbs
q kg
Gender
q Male q Female
C. Child Name (first, last)
Date of Birth (DD/MM/YYYY)
Gender
q Male q Female
D. Child Name (first, last)
Date of Birth (DD/MM/YYYY)
Gender
q Male q Female
If Yes to any question(s), identify the child and provide additional information in the Remarks section.
60. Has there ever been an application for Life or Critical Illness Insurance on any of these children that was
declined, postponed, offered with restrictions or modified with a rating in any way? . . . . . . . . . . . . . . . . . . . .
61. Has any child to be insured ever had any illness, impairment or injury that required treatment, surgery or
hospitalization? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62. Was any child to be insured born prematurely? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Y N
Y N
Y N
Y N
q q q q q q q q
q q q q q q q q
q q q q q q q q
63. Has any child to be insured consulted, or been treated by, any physician or other practitioner for any
known or suspected heart problem, cancer, mental impairment or acquired immunodeficiency syndrome or
ever tested positive for HIV or exhibited any delay in physical or mental development? . . . . . . . . . . . . . . . . . .
q q q q q q q q
64. Has any child to be insured been prescribed any medication or had or been advised to have any treatment or
diagnostic test, whether or not completed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q q q q q q q
65. Is any child to be insured not a legal child or a child of the Proposed Insured(s) whose legal adoption has not
yet been made final? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
66. Are there any other health issues not described above? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
67. Are there any children on whom coverage is not being requested? Provide details in the Remarks section.
q q q q q q q q
q q q q q q q q
PROPOSED INSURED #
DETAILS (provide dates, diagnosis, results of investigations, names of medical advisors, medical facilities and treatment)
30
Application No.
HEALTH HISTORY
Remarks Details of any Yes answers.
If applicable, attach the appropriate completed questionnaire(s).
QUESTION #
PROPOSED INSURED #
DETAILS (provide dates, diagnosis, results of investigations, names of medical advisors, medical facilities and treatment)
31
q Yes
q No
q Yes
q No
32
Application No.
Declaration
I/We have read all of the questions and answers in this application and I/we understand the meaning and importance of them.
THE STATEMENTS AND ANSWERS GIVEN IN THIS APPLICATION ARE TRUE, COMPLETE AND CORRECTLY RECORDED TO THE BEST
OF MY/OUR KNOWLEDGE AND BELIEF.
CITY
DD
/
MM YYYY
Proposed Insured 1 (If Proposed Insured is a minor the signature of a Proposed Insured 2 (If Proposed Insured is a minor the signature of a
Parent or legal guardian is required.)
Witness to signature(s)
If the Owner is an Entity, the signature(s), name(s) and title(s) of the authorized signing officers thereof are required, as stated in the by-laws of the Entity.
**DO NOT DETACH THIS PAGE**
33
c) any question in this application for temporary insurance is left blank or answered yes;
d) at the time this application is made, there is already $2,000,000 (CDN) of temporary life insurance in force with Transamerica on the Proposed
Insured;
e) at the time this application is made, there is already $500,000 (CDN) of temporary critical illness insurance in force with Transamerica on the
Proposed Insured; or
No Advisor is authorized to waive, amend or modify any terms or provisions in this application for temporary insurance or in the temporary insurance agreement.
No representative of Transamerica is authorized to provide temporary insurance coverage if any of the above provisions are true.
PROPOSED
INSURED 1
PROPOSED
INSURED 2
YES NO
YES NO
q q
q q
b) within the last 6 months, been unable to perform regular activities for more than 15 consecutive days because of
sickness or injury? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c) within the last three months, been admitted to a medical facility, been advised to be admitted to a medical facility
or had a diagnostic test and/or surgery recommended or performed (other than for normal childbirth)?. . . . . . . .
d) ever had an application for Life or Critical Illness Insurance on his or her life declined, postponed and/or received a
Life or Critical Illness Insurance policy that was rated or modified in any way? . . . . . . . . . . . . . . . . . . . . . . . . . . .
q q
q q
q q
q q
q q
q q
DECLARATION
I/We declare that I/we have read all of the questions, answers and statements in this Application for Temporary Insurance and all of the terms
and provisions in the Temporary Insurance Agreement, and understand their meaning and importance. I/We further declare that the answers
given in this Application for Temporary Insurance are true, complete and correctly recorded to the best of my/our knowledge and belief. I/We
understand and agree that this Application for Temporary Insurance and the Temporary Insurance Agreement shall be the basis for any insurance
provided thereunder.
Signed at ____________________________________ in the Province of ____________________________________ on
Proposed Insured 1
CITY
Proposed Insured 2
Witness to signature(s)
DD
34
/
MM YYYY
Application No.
q Establish a new P.A.D. Account using: q The same account shown on the first cheque provided with this application
q The account shown on the attached VOID cheque (pre-printed with the Payors name) or
bank Letter of Direction
Date signed:
DD
/
MM YYYY
Signature(s) of Payor(s)
Signature(s) of Payor(s)
35
TERMS AND CONDITIONS OF PARTICIPATION IN THE PRE-AUTHORIZED DEBIT (P.A.D.) PAYMENT PROGRAM
EFFECTIVE DATE
I/We understand and agree that the fully completed Authorization on the previous page will take effect for the Policies applied for, on the latest of
the following dates:
a) the date the Authorization is received by the Head Office of Transamerica Life Canada (Transamerica);
b) the date the full amount of the first premium for the Policy is received by Transamericas Head Office; and
c) the date when the Policy applied for is first placed in full force and effect by Transamerica.
GENERAL
I/We also understand and agree to all of the following terms and conditions:
a) I/We certify that the information provided with respect to the P.A.D. Account is accurate. I/We will provide Transamerica with a new preprinted sample cheque if the P.A.D. Account is changed.
b) The amount drawn on the P.A.D. Account shall be a total of all amounts required to pay the applicable premium payments for all Policies
identified on the reverse and the Policy.
c) The Authorization shall apply to all Policies listed on the reverse and the Policy, including any renewal, conversion or increase in cost of
insurance specified in the c
ontract.
d) The Authorization and all its terms and conditions are subject to all of the terms and provisions of the applicable Policies.
e) If Transamerica has not received a premium payment within the time required, for example, your P.A.D. is not honoured, we will try to redraw your payment within 5 business days. If your premium payment is still not honoured, or for any other reason, then the Policy will lapse
and become null and void, unless it is otherwise stated in the Policy.
f) I/We consent to disclosure of any personal information that may be contained on this Authorization to Transamericas designated financial
institution to the extent necessary for the purposes described in the Authorization and these Terms and Conditions.
TERMINATION
The Authorization will be terminated only on the earliest of the following dates:
a) either I/we or Transamerica provide(s) written notice to the other within 10 days to that effect;
or
b) all of the Policies to which the Authorization applies are no longer in full force and effect.
The revocation of the Authorization does not affect your rights under the Policies.
Any cancellation of this automatic withdrawal arrangement will not affect the agreement between me/us and Transamerica whatsoever with respect
to any contract for goods or services, so long as payment is provided by an alternate method.
I/We further understand and agree that (a) if the Authorization is terminated, a direct modal premium shall become payable for all Policies to
which the Authorization applies; and (b) the amount and frequency of the premium payable under the Policies will be specified in the pages entitled
POLICY DATA/Schedule of Benefits and Premiums attached to the Policy and may be different than the premium payable under a P.A.D. plan.
I/We may revoke my/our Authorization at any time, provided written notice is received no less than 10 days before the next scheduled payment
date. To obtain a sample cancellation form, or for more information on my right to cancel a P.A.D. Agreement, I may contact my financial institution or
visit www.cdnpay.ca.
I/We agree that, for the purpose of this agreement, all pre-authorized debits from my/our account will be treated as Personal. Certain recourse
rights exist in the event that a debit/payment does not comply with this agreement. For example, I/we have the right to receive reimbursement for any
debit that is not authorized or is not consistent with the Authorization. For further information with respect to recourse rights, I/we may contact my/
our financial institution or visit the Canadian Payments Association at www.cdnpay.ca. In addition, I/we may contact Transamerica to make enquiries,
obtain information or seek recourse with respect to any P.A.D. issued by Transamerica, as indicated below.
Transamerica Life Canada
500-5000 Yonge Street
Toronto, ON M2N 7J8
Tel: 1-800-797-2643
36
Application No.
PROPOSED INSURED 1
PROPOSED INSURED 2
_ q Yes
_ q Yes
q No
5. Have you provided the Owner(s) with a copy of the signed policy illustration? (Required for Universal Life only) . . . . . .
Is a signed copy of the Illustration attached? (Required for Universal Life only) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
_ q Yes
_ q Yes
q No
q No
q No
____________________
_ q English q French
6. By signing below, I/we acknowledge that I/we have disclosed, where applicable, the following items to the Owner of
the policy resulting from this application:
a) the company or companies I/we represent;
b) that I/we will receive compensation (such as commissions or a salary);
c) that I/we may receive additional compensation in the form of bonuses, conference programs or other incentives; and
d) that I/we have disclosed any conflicts of interest that I/we may have with respect to this transaction.
Advisors Notes:
Do you have any knowledge of each Proposed Insureds personal habits, health, avocations, finances or reputation that might affect the underwriting
risk? If so, give details below.
______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
CITY
Signature of Advisor
Signature of Advisor
37
DD
/
MM YYYY
TO BE COMPLETED BY DISTRIBUTOR
The individual who wrote this application must be listed below as either Advisor 1, 2 or 3 Advisor and MUST have his/her own SA code.
1. Distributor
Contact Name:_____________________________________________
Distributor Name
and Code:____________________________________________________
Distributor
Contact E-mail:_____________________________________________
Distributor Contact
Phone Number:________________________________________________
Advisor Name or Managing Broker (1): ___________________________________________ Advisor Code: ______________ Share % ________
Unpaid Solicitor Name: ________________________________________________________ Advisor Code: ______________
Advisor Name or Managing Broker (2): ___________________________________________ Advisor Code: ______________ Share % ________
Unpaid Solicitor Name: ________________________________________________________ Advisor Code: ______________
Advisor Name or Managing Broker (3): ___________________________________________ Advisor Code: ______________ Share % ________
Unpaid Solicitor Name: ________________________________________________________ Advisor Code: ______________
q Advisor 1
q Advisor 2
q Advisor 3
2. If you wish to have this policy issued on the same day as another policy or policies for families, partnership or other business reasons, please
give the names of the other Proposed Insured(s) below (not applicable to any policy with a Critical Illness Protection Rider or any
Critical Illness Protection policy):
Group With:
________________________________________________________________________________________or_____________________________
________________________________________________________________________________________or_____________________________
(First Name)
(Last Name)
(Policy Number)
Please note: An underwriting decision needs to be made on ALL Proposed Insureds before any of the grouped policies will be issued, unless
you inform us otherwise.
3. Additional Comments:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
4. UNDERWRITING REQUIREMENTS PROPOSED INSURED 1
Ordered
Ordered From
Submitted
Ordered
Ordered From
Submitted
q Paramedical
q Urine/HIV
q Blood/HOS
q ECG
q Stress Test
q APS DR.
_______________________
q Signed Illustration
q Signed Supplement to the
q Paramedical
q Urine/HIV
q Blood/HOS
q ECG
q Stress Test
q APS DR.
_______________________
q Signed Illustration
q Signed Supplement to the
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
q Inspection/BBR
q MVR
_______________________
_______________________
_______________________
Insurance Application
q Replacement/Disclosure Forms
q Financial Statements
q Questionnaires:
______________________________
______________________________
q Other:
______________________________
______________________________
_______________________
_______________________
_______________________
_______________________
_______________________
q Inspection/BBR
q MVR
_______________________
_______________________
38
_______________________
Insurance Application
q Replacement/Disclosure Forms
q Financial Statements
q Questionnaires:
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q Other:
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Application No.
DETACH AND LEAVE WITH THE PROPOSED OWNER IF THE TEMPORARY INSURANCE CONDITIONS ARE MET.
Receipt for Temporary Insurance
DO NOT DETACH IF NO TEMPORARY INSURANCE IS BEING APPLIED FOR
Transamerica Life Canada (Transamerica) acknowledges receipt of $ ______________________________________________
which is at least the full amount of one monthly modal premium based on the Insurance Application dated
on the life of (print full name of Proposed Insured(s))
DD
/
MM YYYY
on
CITY
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/
MM YYYY
Signature of Advisor
THIS RECEIPT DOES NOT BIND TRANSAMERICA TO PROVIDE COVERAGE UNDER THE TEMPORARY INSURANCE AGREEMENT
UNTIL ALL OF THE TERMS AND CONDITIONS THEREOF ARE SATISFIED.
Note: If you do not hear from Transamerica regarding the proposed insurance within ninety (90) days of the date of your Application, contact your
Advisor or Transamerica at its Head Office, 500-5000 Yonge Street, Toronto, Ontario, M2N 7J8.
b) at the time this application is made, there is already temporary
critical illness insurance in force with Transamerica on the Proposed
Insured for $500,000 (CDN).
c) for life insurance or critical illness coverage, the Proposed Insured(s)
is less than 15 days old or more than 65 years of age;
d) the death of the Proposed Insured(s) results from a suicide attempt
or self-inflicted injury while sane or insane;
e) the death or the critical illness of the Proposed Insured(s) occurs
while committing or attempting to commit a criminal act, including,
without limitation, driving a motor vehicle while under the influence
of alcohol or drugs, intentionally taking any drug other than as
prescribed by a physician, misuse of medication or the use of illegal
drugs or intoxicants; or
f) a material fact has not been disclosed, or has been misrepresented
in the application or any other declaration made in connection to
this application, or the application for temporary insurance.
No benefit under the critical illness insurance will be paid if the Proposed
Insured(s) is/are diagnosed with cancer or die(s) within 30 days of
diagnosis of a covered condition. Our standard Critical Illness policy
provisions, limitations and exclusions shall govern the critical illness
insurance provided under this receipt.
If the Proposed Insured does not qualify for temporary insurance under
the terms and conditions of this agreement, Transamerica will apply the
premium received with the application as payment for the first premium
for the policy issued by Transamerica. If Transamerica declines to offer a
policy, we will return this premium to you.
TERMINATION
This agreement will terminate on the earliest of the following dates:
a) the standard termination date, which is the 90th day after the date
this application is signed;
b) the date on which Transamerica mails a notice to the advisor or
distributor to notify the Owner and/or Proposed Insured(s) in the
application either (a) terminating this agreement, or (b) declining to
issue the policy as applied for; and
c) the date on which the Owner in the application requests the
withdrawal of the application or the applicable application for
temporary insurance.
This agreement terminates automatically when the policy(ies) applied
for become(s) effective, when a counteroffer is tendered to your
independent advisor or distributor or on the termination date, whichever
comes first.
Aegon and the Aegon logo are registered trademarks of Aegon N.V. Aegon Canada ULC and its affiliated companies are licensed to use such marks.
Transamerica and the pyramid design are registered trademarks of Transamerica Corporation. Transamerica Life Canada is licensed to use such marks.
LP2577/14