APPLICATION - UNDERWRITTEN PRODUCTS (P1)

Transcription

1 APPLICATION - UNDERWRITTEN PRODUCTS (P1) SUPERIOR PROGRAM UNIVERSAL LOAN INSURANCE TERM LIFE INSURANCE New sale Change in coverage Contract # Contract conversion Name of representative address of representative* Code % Name of representative address of representative* Code % Firm Code * address required. If you already gave it to us and it didn t change, you can leave this box blank. Current version of the Illustration from our Pyramid sales software is required INVESTED IN YOU. ia Excellence is a trademark and business name under which The Excellence Life Insurance Company operates.

2 1 PREREQUISITE FOR ELIGIBILITY FOR SUPERIOR PROGRAM AND UNIVERSAL LOAN INSURANCE This questionnaire allows you to determine the coverages that may be available to your client. Moreover, its purpose is to save you time and inconvenience and to avoid disappointing your client. It also allows you to determine whether your client may be eligible for Interim Disability Insurance coverage as outlined in Section 15 of this document, subject to the additional questions in Section 15. Please note that to qualify for these products, your client must work at least 21 hours per week on a regular and continuous basis or 8 months per year totalling 1,050 hours per year. For seasonal and contractual workers, the 1,050 hours must be spread over a minimum of 4 months. Your client s application must still undergo a comprehensive review by the Underwriting Department should he or she decide to continue the application process. Primary Insured #1 Primary Insured #2 1- Do you suffer or have you ever suffered from AIDS or AIDS-related complex (ARC), or have you tested positive for antibodies to HIV? 2- Do you suffer or have you ever suffered from: a chronic degenerative disease? (For example: multiple sclerosis, Lou Gehrig s, Alzheimer s, Parkinson s) a permanent physical or intellectual impairment? (For example: paraplegia, quadraplegia, hemiplegia, Down Syndrome) any of these diseases? - insulin-dependent diabetes - hemophilia - fibromyalgia - chronic fatigue syndrome - bipolar disorder - hepatitis C 3- Have you been diagnosed with cancer within the last 12 months or are you currently under any treatment for cancer including hormone therapy? 4- Have you had your driving licence suspended within the last 12 months? 5- Have you ever suffered from or are you currently being investigated for: a heart disease or heart surgery? (For example: cardiovascular disease, heart attack, coronary artery bypass surgery or angioplasty) either of these kidney diseases? - renal failure - polycystic kidney disease If you answered NO to all questions, you MAY BE ELIGIBLE for these products. If you answered YES to questions 1 to 4, you ARE NOT ELIGIBLE for these products. If you answered YES to question 5, you MAY BE ELIGIBLE for coverage IN THE EVENT OF ACCIDENT ONLY. - 2 of 12 -

3 2 REQUESTED CONTRACT(S) Do you pay contributions to Employment Insurance (EI)? Yes No Product(s) Primary Insured #1 Primary Insured #2 TOTAL premium for all contracts Superior Program* Monthly Annual Universal Loan Insurance $ Life Insurance Commission Level commission (default) Up-front commission I, the undersigned, hereby declare that I have read the document titled Illustration and that I agree with its contents. I confirm that the amount of the total premium indicated above is the amount of the total premium shown in the Illustration. Signature of Primary Insured #1 Signature of Primary Insured #2 Signature of Representative *Refusal of the Automatic Increase in Benefits (Superior Program) At each renewal, under certain conditions, an increase to your Life Insurance; Accidental Death, Dismemberment and Loss of Use Insurance; and integrated Disability Insurance benefits will be offered without evidence of insurability. You will have the right to accept or decline the increase. You can also choose to automatically decline this option by initializing the box below. I decline the Automatic Increase in Benefits under the Superior Program Initials of Primary Insured #1 Current version of the Illustration from our Pyramid sales software is required 3 OTHER INSURANCE CONTRACT(S) 3.1 Primary Insured #1 Do you currently hold any other insurance contract(s), except for creditor group insurance? Yes No Type Company Year Issued Amount Under Review In Effect To Replace* Life Dis. $ Life Dis. $ Life Dis. $ * If the insurance applied for replaces any other insurance currently in force, you are required to attach the comparison disclosure statement. (Quebec: disability and life / Outside Quebec: life only) 3.2 Primary Insured #2 Do you currently hold any other insurance contract(s), except for creditor group insurance? Yes No Type Company Year Issued Amount Under Review In Effect To Replace* Life Dis. $ Life Dis. $ Life Dis. $ * If the insurance applied for replaces any other insurance currently in force, you are required to attach the comparison disclosure statement. (Quebec: disability and life / Outside Quebec: life only) - 3 of 12 -

4 4 PRIMARY INSURED #1 4.1 General Information Last name Home address no. street apt./condo First name City Province Postal code Date of birth Gender Home/Cell telephone number Office telephone number Ext. Save age F M Smoking status Smoker* Non-Smoker *You are considered a smoker if, during the past twelve months, you have used tobacco or tobacco derived products in any form, regardless of the frequency of use. Occupation Net annual income Percentage of manual labour and/or requiring physical work Do you work at home more than 50% of the time? $ % Yes No Marital status Single Married Widowed Divorced Common-law spouse Place of birth (country or province) Name of employer / Company Business address Same as home address Date of employment In Canada Always or since Current legal status Canadian citizen Other*, specify: Permanent resident *Please attach a copy of your work permit and proof of your permanent residence application, if any. no. street suite City Province Postal code Mailling address Language of correspondence Home Office English French 4.2 Beneficiary (for Life, AD&D and Overhead Insurance) Last Name First Name Gender Distribution Status* Relationship to Primary Insured #1 F M % Revocable Irrevocable F M % Revocable Irrevocable *A beneficiary is always revocable unless designated specifically as irrevocable, with one exception: where Quebec s Civil Code applies, a beneficiary who is married to or in a civil union with the Primary Insured is always irrevocable unless designated specifically as revocable. 4.3 Family Coverage (dependents) If you selected coverage for your spouse and/or children, please fill out this section for each dependent. Last Name First Name Gender Relationship Date of Birth F M F M F M 4.4 Policyholder (to be completed if other than Primary Insured #1) Last name First name Home address no. street apt./condo City Province Postal code Home/Cell telephone number Date of birth Gender Relationship to Primary Insured #1 F M Last name and first name of the contingent policyholder (life insurance only) - 4 of 12 -

5 5 PRIMARY INSURED #2 5.1 General Information Last name Home address Same as Primary Insured #1 no. street apt./condo First name City Province Postal code Date of birth Gender Home/Cell telephone number Office telephone number Ext. Save age F M Smoking status Smoker* Non-smoker *You are considered a smoker if, during the past twelve months, you have used tobacco or tobacco derived products in any form, regardless of the frequency of use. Marital status Single Married Widowed Divorced Common-law spouse Place of birth (country or province) In Canada as of Always or since Current legal status Canadian citizen Other*, specify: Occupation Net annual income Percentage of manual labour and/or requiring physical work Do you work at home more than 50% of the time? $ % Yes No Name of employer / Company Business address Same as home address Date of employment no. street suite City Province Postal code Mailing address Language of correspondence Home Office English French Permanent resident *Please attach a copy of your work permit and proof of your permanent residence application, if any. 5.2 Beneficiary (for Life, AD&D and Overhead Insurance) Last name First Name Gender Distribution Status* Relationship to Primary Insured #2 F M % Revocable Irrevocable F M % Revocable Irrevocable *A beneficiary is always revocable unless designated specifically as irrevocable, with one exception: where Quebec s Civil Code applies, a beneficiary who is married to or in a civil union with the Primary Insured is always irrevocable unless designated specifically as revocable. 5.3 Family Coverage (dependents) If you selected coverage for your spouse and/or children, please fill out this section for each dependent. Last name First Name Gender Relationship Date of birth F M F M F M 5.4 Policyholder (to be completed if other than Primary Insured #2) Same Policyholder as Primary Insured #1 Last name First name Home address no. street apt./condo City Province Postal code Home/Cell telephone number Date of birth Gender Relationship to Primary Insured #2 Last name and first name of the contingent policyholder (life insurance only) F M - 5 of 12 -

6 6 METHOD OF PAYMENT I hereby authorize The Excellence Life Insurance Company to draw monthly payments from my bank account at my financial institution for the purposes of paying the insurance premium. This authorization concerns pre-authorized debits in the personal category. I will receive, at least 10 days before the first pre-authorized debit and before any change in the date of the debit or in the amount to be debited, a notice to this effect. I will also receive a notice in the event that an instrument is returned by the bank marked insufficient funds or stop-payment order. Note that an administrative fee will apply to any returned instrument and will be payable at the same time as the returned amount and at the next regular payment. Please note that the first pre-authorized debit will be adjusted to reflect the actual period between the first premium paid, the effective date of the coverages and the date you chose for the debits. The debits that follow will correspond to the monthly premium. This authorization may be revoked at any time upon receipt of a written notice from me to The Excellence Life Insurance Company at least ten days before the due date of the next pre-authorized debit. Certain recourses are available to me and I can, for example, dispute a pre-authorized debit if it is not in accordance with this authorization. To obtain the reimbursement form or for any information, you may contact your financial institution or visit For more information, you may contact our Customer Service Department at or by at intouch@iaexcellence.com. 6.1 Payor for Primary Insured #1 Annual premium Please make your cheque out to The Excellence Life Insurance Company. First premium Cheque attached made out to The Excellence Life Insurance Company Pre-authorized debit upon receipt of application Pre-authorized debit on effective date of contract* Payment upon delivery* *An Interim Insurance Agreement is not available with this option. Subsequent premiums Pre-authorized debit on the of each month (1 st to 28 th ) If no date is given, premium will be withdrawn on effective date of contract Same account as for contract # Please attach a specimen cheque marked Void. OR please give us the name of your financial institution Transit number Bank number Account number Last name and first name of payor #1 Signature (as it appears on cheques) Date 6.2 Payor for Primary Insured #2 Illustration for a second payor is required. Annual premium Please make your cheque out to The Excellence Life Insurance Company. First premium Cheque attached made out to The Excellence Life Insurance Company Pre-authorized debit upon receipt of application Pre-authorized debit on effective date of contract* Payment upon delivery* *An Interim Insurance Agreement is not available with this option. Subsequent premiums Pre-authorized debit on the of each month (1 st to 28 th ) If no date is given, premium will be withdrawn on effective date of contract Same account as for contract # Please attach a specimen cheque marked Void. OR please give us the name of your financial institution Transit number Bank number Account number Last name and first name of payor #2 Signature (as it appears on cheques) Date 7 DECLARATION I, the undersigned, hereby: 1) declare that the information provided in this application is true and complete and acknowledge that it constitutes the basis for insurance coverage; 2) understand and accept that, if any misrepresentation or omission is made, The Excellence Life Insurance Company shall not be held to any obligation under any insurance that may be issued to me further to acceptance of my insurance application. Any misrepresentation may result in cancellation of the insurance; 3) undertake to inform the Insurer of any change in my insurability, including my health, between the date this application is signed and the effective date of the requested contract; 4) understand and accept that ia Financial Group, its affiliates and their agents may use and share my personal information with each other so that I can benefit from personalized offers and improved products and services. (If you do not wish your information to be shared within the ia Financial Group, please notify us by at intouch@iaexcellence.com or by mail to The Excellence Life Insurance Company, c/o Customer service, 5055 Metropolitain East, Suite 202, Montreal (Quebec), H1R 1Z7.) Signed at City Signature of Primary Insured #1 Signature of Policyholder if other than Primary Insured #1 Signature of Representative Signature of Primary Insured #2 Signature of Policyholder if other than Primary Insured #2 Date - 6 of 12 -

7 8 NOTICE REGARDING MIB INC. (MIB) The primary objective of the Company is to provide its clients with financial security at the lowest possible cost. In order to achieve this goal in a fair and equitable manner with respect to all policyholders, the Company must assess the risk associated with every insurance application. Your application is reviewed based on information from various sources of data that you have provided regarding your medical history, the results of any medical examination or test deemed necessary, reports received from the physicians you consulted and the hospitals where you stayed as a patient, as well as information regarding your character, your financial reputation, your personal expenses and your lifestyle. All information concerning your insurability is considered confidential. However, the Company or its reinsurers may submit a summary of that information to MIB Inc., a non-profit organization created by life insurance companies that exchanges information on behalf of its member companies. If you purchase life or health insurance from another MIB member company, or if you claim benefits from that company, MIB Inc. will, upon request, provide that company with the information it holds regarding you. If you send MIB Inc. a request to this effect, MIB Inc. will take steps to provide you with the information in your record. If you challenge the accuracy of MIB s information, you may send a request to correct your record to the following address: MIB Inc., 330 UNIVERSITY AVENUE, TORONTO, ONTARIO, M5G 1R7 TEL. (416) The Company and its reinsurers may also communicate the information in their records to other life insurance companies with which you apply for life or health insurance or with which you file a claim. NOTICE REGARDING THE CREATION OF A PERSONAL FILE The personal information that the Company holds or will hold concerning you will be treated confidentially and kept in a file, the purpose of which is to allow you to benefit from various financial insurance services and related services that the Company offers. The file will be consulted only by authorized personnel, including the Company s reinsurers, who must access the information as part of their work. You may access your file and request corrections to the information therein if you show that the information is untrue, incomplete, ambiguous, no longer valid or unnecessary. In this case, you must send a written request to the Access to Information Officer at the Montreal head office. The Company may create a list of clients for business or philanthropic prospecting purposes. However, it is your right to have your name removed from that list by sending a written request to the Access to Information Officer at the Montreal head office (5055 Metropolitain Blvd East, Suite 202, Montreal, Quebec, H1R 1Z7). DETACH AND GIVE THIS SECTION TO THE PRIMARY INSURED 9 AUTHORIZATION TO COLLECT AND COMMUNICATE PERSONAL INFORMATION TO THIRD PARTIES 9.1 Primary Insured #1 The Excellence Life Insurance Company 5055 Metropolitain East, Suite 202 Montreal (Quebec) H1R 1Z7 Telephone : / I, the proposed insured and applicant, hereby authorize any person or any other public, quasi-public or private institution holding my personal information, including: any health care professional, health or social service establishment, the Régie de l assurance maladie du Québec, any insurance or reinsurance company, MIB Inc., financial institutions, personal information agents or professional investigation agencies, financial consultants, my employer or ex-employer, the policyholder and any other body holding personal, administrative, medical or health-related information concerning myself to supply this information to The Excellence Life Insurance Company and their respective reinsurers for the risk assessment, for case management or for any investigation required for the study of any claim. I also authorize The Excellence Life Insurance Company to exchange personal information with these people and entities, as well as with their reinsurers, as required. A photocopy or electronic version of this authorization is as valid as the original. Last name and first name of Primary Insured #1 Signature of Primary Insured #1 Date 9.2 Primary Insured #2 The Excellence Life Insurance Company 5055 Metropolitain East, Suite 202 Montreal (Quebec) H1R 1Z7 Telephone : / I, the proposed insured and applicant, hereby authorize any person or any other public, quasi-public or private institution holding my personal information, including: any health care professional, health or social service establishment, the Régie de l assurance maladie du Québec, any insurance or reinsurance company, MIB Inc., financial institutions, personal information agents or professional investigation agencies, financial consultants, my employer or ex-employer, the policyholder and any other body holding personal, administrative, medical or health-related information concerning myself to supply this information to The Excellence Life Insurance Company and their respective reinsurers for the risk assessment, for case management or for any investigation required for the study of any claim. I also authorize The Excellence Life Insurance Company to exchange personal information with these people and entities, as well as with their reinsurers, as required. A photocopy or electronic version of this authorization is as valid as the original. Last name and first name of Primary Insured #2 Signature of Primary Insured #2 Date - 7 of 12 -

8 10 CHECKLIST FOR TELEPHONE INTERVIEW To facilitate the telephone interview, please have the following information on hand: 1- Full name and contact details of any specialist(s) consulted in the past five years and name of hospital where any surgery or special tests took place: 2- Full name and contact details of the physician or location able to provide us with your complete medical record, including the date and reason of your last visit: 3- List of your prescribed drugs and dosage (if possible, obtain the license number of your family doctor appearing on your medication): 4- If you have insurance coverage for your children, please specify the height and weight for each: The following topics will also be discussed during the interview: Alternative medicine practitioner: Acupuncturist, chiropractor, osteopath; Criminal record: Date of conviction, reason, are you awaiting proceedings; Lifestyle: Smoking, drinking and drug use (frequency, quantity and type), foreign travel (when, destinations and trip length); Driving record: Loss of driver s licence (when, why), driving offences (how many, when, why). Please allow approximately 20 to 45 minutes for the telephone interview. Time will vary depending on the medical information required. If you need to reschedule, please contact our Customer Service Department at ADDITIONAL INFORMATION Please provide any additional information that may be helpful to the Insurer in processing this application. - 8 of 12 -

9 12 TELEPHONE INTERVIEW ORDER If a telephone interview is required, a telephone interview analyst will contact your client to conduct the interview. The telephone interview will last approximately 20 to 45 minutes. Time will vary depending on the medical information required. Ideal choices for the telephone interview Availability Primary insured #1 Primary insured #2 Weekday: 1 st CHOICE Time of day: AM PM EVENING AM PM EVENING Telephone number: Weekday: # # 2 nd CHOICE Time of day: AM PM EVENING AM PM EVENING Telephone number: # # If you have requested an evening appointment, do you authorize us to contact you during the day only to schedule the telephone interview? Yes No If yes, please indicate the phone number where you can be reached: Other relevant information you wish to add: To order a telephone interview, please call Have you ordered your telephone interview? Broker ia Excellence must order 13 MEDICAL REQUIREMENTS ORDER Were the medical requirements already ordered? No If no, please go to section 14. ia Excellence will order them. Yes If yes, a) When? b) By who? Broker MGA c) For whom? ia Excellence Industrial Alliance Other insurer: d) ia Excellence must obtain them ia Excellence will receive them automatically Name of Insurer Please indicate the medical requirements that were ordered: Primary insured #1 Primary insured #2 TESTS ORDERED INFORMATION ON THE ORDER TESTS ORDERED INFORMATION ON THE ORDER Paramedical exam (including vital signs) Blood profile Blood profile with PSA Service provider: Medaxio (former Medisys) Portamedic (Hooper-Holmes) QUS Paramedical exam (including vital signs) Blood profile Blood profile with PSA Service provider: Medaxio (former Medisys) Portamedic (Hooper-Holmes) QUS Urine HIV Watermark Urine HIV Watermark Vital signs Resting ECG Other: Specify Vital signs Resting ECG Other: Specify Reference No.: Reference No.: Inspection report (will be ordered by ia Excellence) Inspection report (will be ordered by ia Excellence) - 9 of 12 -

10 14 ATTENDING PHYSICIAN S REPORT This questionnaire allows you to know under what circumstances we will order an attending physician s report for your client. 1- Have you ever consulted or been treated for, or have you been told that you suffered from, any of the following illnesses or conditions: - hepatitis - cancer (any location) - stroke, transient ischemic attack (TIA) 2- Are you currently under supervision for another illness requiring three or more follow-up visits a year? If so, which: Primary insured #1 Primary insured #2 3- Have you ever consulted or been treated for, or have you been told that you suffered from, any of the following illnesses or conditions: - angina, heart attack (with or without bypass surgery, angioplasty) - chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema - major depression (in the past 12 months) or bipolar affective disorder If you answered YES to questions 1 or 2, we will order an attending physician s report for the SUPERIOR PROGRAM and UNIVERSAL LOAN INSURANCE. If you answered YES to questions 1 to 3, we will order an attending physician s report for our LIFE INSURANCE products. Name, full address and telephone number of physician in possession of a complete record of your client. 15 INTERIM INSURANCE AGREEMENT (Superior Program and Universal Loan Insurance) Complete this section only if you answered NO to all questions in Section 1 of this document (prerequisite for eligibility). You may be ELIGIBLE for this Interim Insurance Agreement for our SUPERIOR PROGRAM and UNIVERSAL LOAN INSURANCE products, subject to the following additional questions: Primary insured #1 Primary insured #2 1- I declare that I have been performing all the usual duties of my occupation on a continuous basis for the past six months. 2- I declare that I am not awaiting surgery or hospitalization. 3- In the past 36 months, have you consulted or been treated by a physician or other health professional or been prescribed drugs for: A problem with your back or spine (including a herniated disc)? An emotional or psychiatric disorder or any other mental or nervous disorder? (For example: depression, burnout, anxiety, insomnia) If you answered NO to questions 1 or 2, you ARE NOT ELIGIBLE for this Interim Insurance Agreement. If you answered YES to question 3, you ARE ELIGIBLE, but WITH A SPECIFIC ECLUSION for the declared condition. Declaration I understand and declare that: 1. If any questions in Section 1 are answered YES or questions 1 or 2 in Section 15 are answered NO or left blank, I am not eligible for this Interim Insurance Agreement. 2. I have read the terms and conditions related to the limitations, exclusions, effective date and termination of this Interim Insurance Agreement as set out in Section 18 of this document. 3. The information in any declaration I have made to the Insurer is true and complete and constitutes the basis for this Interim Insurance Agreement. I understand and accept that, if any misrepresentation or omission is made, the Insurer shall not be held to any obligation under this Interim Insurance Agreement and that it will be null and void. I certify that all the requested explanations were provided by my representative to my satisfaction. Date: Signature of Primary Insured #1 Signature of Primary Insured #2 Signature of Representative - 10 of 12 -

11 16 RECEIPT FOR INTERIM INSURANCE AGREEMENT (Superior Program and Universal Loan Insurance) An amount of: $ Was received on: Signature of Representative: DETACH AND GIVE THIS SECTION TO THE PRIMARY INSURED 17 RECEIPT FOR TERM LIFE INTERIM INSURANCE AGREEMENT Term life insurance begins on the date the application is signed. It is payable to the beneficiary (or beneficiaries) named in the application in the event of the applicant s death. The Excellence Life Insurance Company agrees to provide term life insurance to all proposed Insureds based on the conditions stipulated on the back of this receipt. It is understood that the sum of $ (full monthly premium or annual premium, as the case may be) was paid to The Excellence Life Insurance Company when this application was signed. I have read and signed this term life insurance Interim Insurance Agreement and I certify that all the requested explanations were provided by my representative to my satisfaction. Date: Signature of Primary Insured #1 Signature of Primary Insured #2 Signature of Representative DETACH AND GIVE THIS SECTION TO THE PRIMARY INSURED - 11 of 12 -

12 18 INTERIM INSURANCE AGREEMENT (Superior Program and Universal Loan Insurance) The Excellence Life Insurance Company guarantees payment of the selected benefits subject to the following conditions: The Insured must answer all the eligibility questions in section 15 of this document. If any questions in Section 1 are answered YES or questions 1 or 2 in section 15 are answered NO or left blank, the Insured is not eligible for this Interim Insurance Agreement. The Insured must make a payment in the amount of the monthly premium or the annual premium according to the chosen method of payment. This payment must be made through pre-authorized debit or a personal cheque made out to The Excellence Life Insurance Company. The payment must be honoured upon initial presentation. Limitations and Exclusions This Interim Insurance Agreement does not provide the following coverages: Extended Health Insurance, Dental Care Insurance and Critical Illness Insurance. If question 3 in Section 15 is answered YES, no benefit shall be payable when an event giving rise to a claim results directly or indirectly from any of the conditions thus declared. No benefit is payable when an event giving rise to a claim results from an illness or accident for which the Insured consulted a health professional and/or received medical treatment in the 12 months prior to the effective date of this Interim Insurance Agreement. The information in any declaration made to the Insurer is true and complete and constitutes the basis for this Interim Insurance Agreement. If any misrepresentation or omission is made, the Insurer is held to no obligation under this Interim Insurance Agreement, which will be null and void. All the coverages under this Interim Insurance Agreement are also subject to the conditions, exclusions and limitations set out in the brochure and the requested contract. This includes, in particular, the exclusion for suicide and attempted suicide by the Insured. In case of total disability, the disability insurance coverage is limited to a benefit period of two years and subject to a 90-day waiting period. Effective Date and Termination of the Interim Insurance Agreement The Interim Insurance Agreement takes effect at the latest of the following dates: the date the insurance application is received at the Insurer s head office, including Sections 1 and 15, duly completed and signed by the Insured; signature date of the pre-authorized debit provided the payment is honoured upon presentation; where no cheque is attached to the application, the date the Insurer receives the cheque, provided the payment is honoured upon presentation. The Interim Insurance Agreement expires at the earliest of the following dates: the effective date of the contract applied for; the date the Insured requests that the insurance application be cancelled; the date the Insurer mails the Insured a notice of termination of interim insurance; the date the application is refused or is not accepted as presented, whether or not the Insured has been notified; 90 days after the date this Interim Insurance Agreement is signed. Review of the application may continue, but the interim insurance is no longer in force. No representative of The Excellence Life Insurance Company has the authority to amend this Interim Insurance Agreement or to waive any of its conditions. 19 TERM LIFE INTERIM INSURANCE AGREEMENT Premium Payment: The payment cannot be postdated. The full monthly premium or annual premium must be submitted with the application. The payment must be honoured upon initial presentation. Termination of Coverage: The insurance under this Interim Insurance Agreement terminates automatically at the earliest of the following events: a) the effective date of the insurance under the requested contract: b) the date the Insured requests that the insurance application be cancelled; c) the date The Excellence Life Insurance Company cancels or refuses the application; d) 90 days after the date this Interim Insurance Agreement is signed. Review of the application may continue, but this term insurance will no longer be in force. Misrepresentation or Omission: If any misrepresentation or omission is made in any declaration made to the Insurer, the Insurer shall not be held to any obligation under this Interim Insurance Agreement, which will be null and void. In this case, any premium paid under this Interim Insurance Agreement will be refunded to the payor. Limitation: The amount of life insurance under this Interim Insurance Agreement is the total of all sums insured indicated in this application and any other life insurance Interim Insurance Agreement with The Excellence Life Insurance Company, to a maximum of $300,000 per Insured. Exclusions: No life insurance benefit will be payable under this term insurance for any Insured who: a) does not meet the eligibility criteria for the selected contract; b) has had an application for life, disability, critical illness, individual or group insurance with another company refused, deferred or amended in any way; c) suffers, or has suffered, from a disease or condition of the cardiovascular system, circulatory system or liver, diabetes, cancer, chronic kidney or lung disease; d) suffers, or has suffered, from a problem with the immune system, AIDS or AIDS-related complex or has tested positive for exposure to the AIDS virus; e) has symptoms for which he or she has not yet consulted a physician or has been advised to receive treatment or undergo tests that have not yet been carried out; f) has, in the past two years, travelled or lived outside Canada or the United States of America for over one month in the course of the same year or intends to do so in the next 90 days; g) commits suicide, attempts suicide or deliberately harms himself or herself, whether he or she is sane or insane of 12 -