Application for conversion and exercising Guaranteed insurability benefit (GIB) option

Transcription

1 Application for conversion and exercising Guaranteed insurability benefit (GIB) option Instructions and advisor s report Section Page Advisor s report Client identity verification Third party determination Acknowledgement of variability Application for conversion and exercising GIB option General information Plan details SunUniversalLife additional information 8 4 Sun Limited Pay Life additional information 9 5 Payments Acknowledgement and agreement Instructions Use this application to apply for conversion of all eligible Sun Life Financial life insurance products offered by Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. Please give page 13, containing the Sun Life Financial Privacy Statement for Canada to the proposed insured. Important information you should know E Page 1 of 13

2 Advisor s report Payment information Payment made with this application Future payment frequency Amount of future periodic payments $ Yearly Monthly $ Advisor information For investment dealer business, leave percentage share blank. Shares must be a minimum of 10%. Is commission being shared? Yes No. If yes, please provide details. Name of lead service advisor commission Code Share Office % Name of advisor sharing commission Code Share Office % Check a box below to indicate your distribution office as well as print your office name: IDA/MFDA Intercorporate (GWL, IG, F55) MGA/PPGA Name of office Additional comments or special instructions Attach a business card. If SunUniversalLife or Sun Limited Pay Life is applied for, third party determination must be completed and signed by the advisor. Advisor s declaration I confirm I ve reviewed with each applicant, proposed insured and PAC payor, their questions in this application and this information is accurate, full, complete and true. To the best of my knowledge, the application has all facts material to the insurance applied for. I confirm I saw every person sign this form. Advisor s name (first, middle, surname) Signature of advisor Office Advisor code address E Page 2 of 13 AGTSTMTE

3 Client identity verification Complete the Client identity verification and Third party determination sections on SunUniversalLife and Sun Limited Pay Life insurance applications. Verification of the applicant s identity The Proceeds of Crime (Money Laundering) and Terrorist Financing Act requires a client s identity to be verified by referring to certain documents. The law also requires the existence of any third parties, if any, to be determined and recorded. Please complete the requested information below. a) What is the purpose of this insurance? Business Personal b) Has verification of identity, for all applicants on this application, already been provided on previous applications dated June 2002 or later? (If no, please complete the requested information below. If yes please provide a policy number for each applicant.) Yes No Note: We reserve the right to refuse cash as a form of payment. Individual(s) Provide the information below if any applicant is an individual. Refer to passport, birth certificate, driver s licence, etc. Name Date of birth (d/m/y) Type of document Document number Place of issue Applicant 1 Applicant 2 (if applicable) Applicant 3 (if applicable) Sun Life Financial will conduct a corporate search to ascertain the corporation s existence. Corporation Provide the corporate information below if any applicant is a corporation. Official corporate name Address Place of incorporation Corporate registration number Refer to partnership agreement, articles of association, etc. Non-corporate entity Provide the information below if any applicant is an association, partnership, etc. Name Address If reviewed a hard copy of the relevant document, attach a copy. If reviewed an electronic copy, provide the following additional information. Registration number Place of issue Type of record Source of record E Page 3 of 13 PIVERIDE

4 Third party determination This section must be completed and signed by the advisor. You are required to determine if any applicant is acting on behalf of a third party. If so, record the third party s information. Is any applicant acting on behalf of a third party or does a third party have the use of or access to the policy/account? Yes No If yes, collect the following information on the third party. Name Relationship to applicant Address Occupation/Business If a corporation, registration number Place of issue Cannot determine but I have reasonable grounds to believe there is a third party. Reason I have verified the identity of the applicant(s) by referring to the documents mentioned above. Reasonable effort has also been exercised to determine if any applicant is acting on behalf of a third party. Name of the advisor Signature of advisor Date (d/m/y) X Acknowledgement of variability I acknowledge there are many variables that can affect an insurance policy s performance, including the following (where applicable): the type of and future investment performance of the Investment option(s) selected the timing and amount of future deposits to and withdrawals from the policy the cost of insurance mortality and morbidity rates, lapse rates and expenses policy loans, and future federal income tax rules and provincial income and premium taxes. More specifically, I understand interest rates and the performance of securities markets in particular, can fluctuate significantly and that even a small change in any one of these variables could have a dramatic negative or positive impact on the policy s non-guaranteed benefits and values. I understand that past performance does not predict nor is it a good indicator of future results. I acknowledge that any illustration(s) shown to me in connection with the sale of the policy will not become part of the policy and was provided solely to show me how policy values may change over time based on different sets of assumptions. I understand that, unless indicated as Guaranteed, the benefits and values in an illustration are not guaranteed, are hypothetical only and are based on assumptions that are certain to change. I realize they are neither an estimate nor a guarantee of future policy performance. I understand actual results will differ upward or downward from those illustrated, because they are highly dependent upon a number of variables (including those listed above) and that even a small change in any one of these variables could have a dramatic negative or positive impact on the non-guaranteed figures shown in an illustration. E Page 4 of 13 PIVERIDE

5 Application for conversion and exercising GIB option Policy no. In this application you and your refer to the proposed insured and the applicant. We, us, our and the Company refer to Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. This is a conversion from an: Individual policy # Group policy/certificate # Please PRINT clearly Other eligible policy # (specify) 1 General information If the mailing address differs from the residence address, please provide details in the Advisor s report. Information about the proposed insured Name (first, middle initial, surname) Male Date of birth (d/m/y) Female Former surname (if any) Residence address (street number and name, apartment or suite) Place of birth (city and country) City Province Country Postal code Social Insurance Number (required for tax reporting purposes) Driver s licence number Province Occupation (please specify job title and duties) Name and address of employer Home phone number ( ) Business phone number ( ) Does the proposed insured want to retain age? Yes No (Note: Age may be retained up to 90 days.) Complete if the applicant is not the proposed insured. Information about the applicant Name (first, middle initial, surname) Male Date of birth (d/m/y) Relationship to the proposed insured Female Residence address (street number and name, apartment or suite) City Province Country Postal code Social Insurance Number (required for tax reporting purposes) Complete if applicant is not the proposed insured. Occupation (please specify job title and duties) Name and address of employer Is there a contingent owner? Name (first, middle initial, surname) Home phone number ( ) Business phone number ( ) Relationship to the proposed insured E Page 5 of 13

6 1 General information (continued) For SunUniversalLife only, for Early death benefit (EDB) election on Joint last-to-die, with the Insurance amount plus fund or Fund builder option, complete EDB Election and/or change form. For Sun Limited Pay Life only, for Early death benefit (EDB) election on Joint last-to-die, with minimum guaranteed death benefit of $250,000, complete EDB Election and/or change form. Your beneficiaries If not completed, the beneficiary will be the applicant or the estate of the applicant. Primary beneficiaries (share of benefits must add up to 100%) % share of Relationship to proposed insured benefits to Name (first, middle initial, last) (In Quebec, relationship to applicant) be paid (for first proposed insured) (for second proposed insured) Contingent beneficiaries (share of benefits must add up to 100%) % share of Relationship to proposed insured benefits to Name (first, middle initial, last) (In Quebec, relationship to applicant) be paid (for first proposed insured) (for second proposed insured) Total 100% Total 100% Total 100% Total 100% In Quebec, if you name your legal spouse (marriage or civil union) as the beneficiary, this designation will be irrevocable unless you check this box: Revocable Complete when a minor beneficiary has been named in any of the above beneficiary designations. Trustee for a minor beneficiary (In Quebec, naming a trustee on this form is not sufficient to establish a trust. Consult your legal advisor for help.) a) Beneficiaries: I appoint b) Contingent beneficiaries: I appoint as a trustee to receive any payments on behalf of any named beneficiary, during his or her minority. The trustee may apply such payments solely for the support, maintenance, education and benefit of such a beneficiary at the discretion of the trustee. E Page 6 of 13

7 2 Plan details Complete for all applications. 1. In the last 12 months, has the proposed insured smoked or used cigarettes, cigarillos, small or large cigars, pipes, marijuana, hashish, chewing tobacco, nicotine gum or patches, or tobacco in any other form? Yes No 2. Is the proposed insured currently claiming on their disability benefit? Yes No All conversions must meet current product minimums and meet all product and benefit availability guidelines. For any amount of insurance in addition to the amount available for conversion, a new application for life insurance must be completed. If converting from universal life, only the fund in excess of the surrender charges will be transferred to the new policy. If applying for rate change basis please complete application for policy change and/or reinstatement. Complete for conversions only: Conversion of: Term plan Sun Limited Pay Life Group plan Benefits Enhancement Universal life coverage Other or Convert the full amount Partial conversion amount to be converted $ amount not to be converted is to: remain in-force or be cancelled New basic insurance amount $ Convert to: SunUniversalLife (complete UL information on the next page) Cost of insurance: Guaranteed yearly term, or Guaranteed level term or Sun Limited Pay Life 10 year 15 year 20 year or SunLifetimeAlternative or or or Benefits details: Sun One year term (available on group conversions only) Sun Term to 65 (available on group conversions only) or Existing policy # Other/ Benefit Keep all the policy benefits that are available for conversion Delete all existing policy benefits Keep these benefits only (describe): _ Enhancement $ _ Choose: Lifetime or 10 Year Guarantee Include a copy of the client s termination notice with this application. Complete for group conversions only: Group company name Group policy number Date the group insurance was terminated (or the last day worked, or the benefits expiry date) (d/m/y) Eligible amount $ Is this a spousal conversion? Yes No. If yes, complete the following: Spouse s name Spouse s SIN Spouse s date of birth (d/m/y) Please have spouse sign on page 12. Complete for exercising GIB options only: Amount of option being exercised $ _ Eligibility relates to the person being insured: Age _ First marriage on _ date (d/m/y) Child born on _ date (d/m/y) Legal adoption _ date (d/m/y) Other _ E Page 7 of 13

8 3 SunUniversalLife - additional information Complete this section only if you are applying for a new SunUniversalLife insurance policy. If an investment mix change is required on an existing universal life policy, complete a Universal Life Client service request form. Any of the options chosen in this section only apply to the new policy, and not to the options on any existing universal life policy. Your death benefit options Choose one of the following: Level insurance amount Indexed insurance amount (please check one) at % per year (specify between 1% and 8%, in multiples of 0.25%), or at the annual rate of Canada's Consumer Price Index (to a maximum of 8% per year) Insurance amount plus your policy fund value For multiple life coverage, the fund value will be paid as a proportion of each insurance amount to the total, unless you tell us your fund value is to be paid with the first or last settlement of basic benefits under the policy. Fund builder Fund builder is a variation of the Insurance amount plus fund option. Starting with the policy anniversary, the insurance amount will be reduced annually to the lowest level that maintains your policy s tax-exempt status. Stop annual reductions when the insurance amount reaches $ Investment bonus (must be indicated) Yes No Your Investment options You must allocate your payments to any of the following Investment options. Your choices must be in multiples of 5 %, and they must add up to 100 %. Each of your investment accounts must also have a minimum amount of $ If you have selected an Investment option which is no longer available, but is not reflected in this application, we will allocate your selection to the Daily interest account (DIA). We ll tell you what options are then available for you to make an alternative selection. You can tell us which option you want to use in place of the option that s no longer available. Interest rate accounts Percentage Accounts based on indices Percentage Accounts based on managed funds Percentage Daily interest account American Equity CI Portfolio Series Balanced Guaranteed interest accounts (GIAs) 1 year American Technology Canadian Bond CI Canadian Investment CI Canadian Investment 3 year Canadian Equity CI Global 5 year European Equity CI Portfolio Series Balanced Growth 10 year Foreign Equity CI Portfolio Series Conservative Balanced 20 year FPX Balanced CI Harbour FPX Growth CI Harbour Growth & Income FPX Income CI Signature High Income Japanese Equity CI Signature Income & Growth Pacific Equity CI Value Trust Corporate Class Fidelity Growth America Fidelity Global Fidelity NorthStar Fidelity True North Mackenzie Cundill Canadian Balanced Mackenzie Cundill Value Mackenzie Ivy Foreign Equity McLean Budden American Equity McLean Budden Balanced Growth McLean Budden Canadian Equity Value PHN Balanced PHN Bond PHN Canadian Equity PHN Dividend Income E Page 8 of 13 Sub total + Sub total + Sub total % % % = 100%

9 3 SunUniversalLife - additional information (continued) Your GIA earnings will automatically compound until the account matures. On maturity, your GIA account balances will automatically transfer to the Activity account unless you check this box: Rollover to a new account of the same term In what order do you want your investment account withdrawals and transfers to be processed? If not specified, your withdrawal order will be Proportional. (A change to this section is not available after the policy is issued. Check one.) Standard order: or Activity account Daily interest account Accounts based on the performance of indices Accounts based on the performance of managed funds GIAs (nearest to maturity) of managed funds Alternative order: or Activity account Daily interest account GIAs (nearest to maturity) Proportional order: Activity account Proportional accross all options Maintaining your policy s tax-exempt status Please check one of the boxes below (do not check a box if you have chosen Fund builder death benefit). Retain insurance amount Increase insurance amount as required (to a maximum of 8%) but reverse the increase when this can be done without losing tax-exempt status (please note the cost of insurance will be changed accordingly), or Increase insurance amount as required (to a maximum of 8% and the cost of insurance will be increased accordingly), but do not reverse the increase. In addition, check a box below to tell us what we should do with excess funds. (Designate a service account for any excess funds.) Refund them to the policy owner, or Transfer them to a service account, which you may choose as any one of the Investment options available under this policy (see Investment options) Name of Investment option for service account 4 Sun Limited Pay Life - additional information Your Investment options You must allocate your payments to any of the following Investment options. Your choices must be in multiples of 5 %, and they must add up to 100 %. Each of your investment accounts must also have a minimum amount of $ Interest rate accounts Percentage Accounts based on indices Percentage Daily interest account Guaranteed interest accounts (GIAs) 1 year American Equity American Technology Canadian Bond 3 year Canadian Equity 5 year European Equity 10 year Foreign Equity 20 year Long Term Managed Portfolio FPX Balanced FPX Growth FPX Income Japanese Equity Pacific Equity Sub total % + Sub total % = 100% E Page 9 of 13

10 4 Sun Limited Pay Life - additional information (continued) Your GIA earnings will automatically compound until the account matures. On maturity, your GIA account balances will automatically transfer to the Activity account unless you check this box: Rollover to a new account of the same term In what order do you want your investment account withdrawals and transfers to be processed? If not specified, your withdrawal order will be Proportional. (A change to this section is not available after the policy is issued. Check one.) Standard order: or Activity account Daily interest account Accounts based on the performance of indices GIAs (nearest to maturity) Long Term Managed Portfolio Maintaining your policy s tax-exempt status (Designate a service account for any excess funds.) Check a box below to tell us what we should do with excess funds. Refund them to the policy owner, or Transfer them to a service account, which you may choose as any one of the Investment options available under this policy, excluding Long Term Managed Portfolio (see Investment options) Name of Investment option for service account Alternative order: or Activity account Daily interest account GIAs (nearest to maturity) Accounts based on the performance of indices Long Term Managed Portfolio Proportional order: Activity account Proportional per account balance E Page 10 of 13

11 5 Payments Payments will not be taken from your account until the policy is in effect unless you have selected initial payment in section Method of payment information. We reserve the right to refuse cash payments. Pre-authorized Yes No If yes, please complete section 2. All payments chequing including the initial payment, will be withdrawn from the (PAC) account shown in section 2. Annual Yes No If yes, submit the total annual payment to your advisor at the time the application is completed. Make cheque payable to Sun Life Assurance Company of Canada. $ Amount paid to advisor with application. Payment on delivery Yes No Not applicable if applying for temporary life insurance or group conversion. Complete for SunUniversalLife and Sun Limited Pay Life applications. Payment information $ Amount of future periodic payments. We will immediately withdraw 1/12 th of the annual payment as the initial payment. 2. Pre-authorized chequing ( PAC ) authorization a) Add to existing PAC that is paying for Sun Life Financial policy - Yes No (Regular PAC withdrawals for this policy will be withdrawn on the same day each month as the existing PAC for the policy number listed above, unless otherwise indicated in e.) b) Withdraw funds to pay the initial payment Yes No (If yes, complete d and e. If 'no', submit the total initial payment to your advisor at the time the application is completed.) c) Start a new PAC Yes No (If yes complete d and e. Regular PAC withdrawals for this policy will start one month from the policy date unless otherwise indicated in e.) d) Attach a sample cheque marked void OR complete the following: (Only accounts with chequing privileges may be used.) Name and address of financial institution Transit number Account number e) Sun Life Assurance Company of Canada (Company) will withdraw funds to pay all payments, including the initial payment if selected, on this policy each month from the bank account shown on the sample cheque attached or any account designated. All persons whose signatures are required to sign on this account must sign the authorization on page 12. For a joint account requiring more than one signature to withdraw funds, all the depositors must sign the authorization on page 12. The initial payment will be withdrawn immediately. date (d/m/y) Regular PAC withdrawals will start one month from the policy date or on The Company will charge a fee and may cancel the pre-authorized chequing if any withdrawal is not honoured. The payor may cancel this authorization at any time by giving the Company 10 days written notice. E Page 11 of 13

12 6 Acknowledgement and agreement Acknowledgement and agreement The applicants confirm they ve received, read and agree to: the Sun Life Financial Privacy Statement for Canada, and the Certificate of temporary insurance, when applicable. Declaration The applicants, proposed insureds and pre-authorized chequing (PAC) payors confirm: they were present when their portion of this application with Sun Life Assurance Company of Canada (Company) was completed they had an opportunity to review all of their answers and statements recorded in the application this information is full, complete and true, and may be relied upon by the Company they understand that if they do not fully, completely and truthfully answer all of their questions (if they misrepresent any of their answers or statements) the Company may void the policy they agree that their personal, medical and financial information, may be shared as set out in the Sun Life Financial Privacy Statement for Canada they have read and agree to the acknowledgement of variability they are satisfied with the level of product information they received before signing this application and are aware that additional product information is available to them under the 'Product & Services' section of the website at or by calling our toll-free Customer Service Centre at PAC payors authorize the Company to withdraw funds to pay the required payments on this application/policy from the account given in the application or any account the payors request in the future PAC payors warrant and guarantee that all persons whose signatures are required to sign on this account have signed this authorization PAC payors agree to the Company s policy of charging a fee and right to cancel the PAC for any withdrawal that is not honoured, and PAC payors are aware that they have the right to cancel their PAC authorization by giving the Company 10 days written notice. Authorization of all proposed insureds The proposed insureds (parent or legally appointed guardian, if proposed insured is under age 16 (18 in Quebec)) authorize: any physician, medical practitioner, medically-related facility, insurance company, investigation agencies, the Medical Information Bureau or other organization, institution or person, including the members of the Sun Life Financial group of companies, which includes this Company, that have records or knowledge of any proposed insured s health, to give only that information necessary for underwriting, administration of insurance and claims paying purposes to the Company, its representatives and its reinsurers the performance of such examinations, x-rays, electrocardiograms, blood profiles, and tests for HIV (AIDS) antibody, if needed to underwrite this application, and the Company to release only the necessary personal information obtained during the underwriting process to their personal physician or to the Medical Information Bureau, and for any infectious or communicable disease, to the Medical Officer of Health where required by law. A photocopy of this authorization is as valid as the original. Location signed (City, Province) Date (d/m/y) Signature Applicant (indicate title of signing officers if applicable) X Applicant (indicate title of signing officers if applicable) X Proposed insured (if other than applicant, if under age 16) (18 in Quebec) signature of parent or guardian) X Proposed insured (if other than applicant) X PAC Payor (if other than applicant or proposed insured) X These products are issued by Sun Life Assurance Company of Canada E Page 12 of 13 PAPRSIGE

13 Important information you should know Sun Life Financial Privacy Statement for Canada At Sun Life Financial, protecting your privacy is a priority. We maintain a confidential file in our offices containing personal information about you and your contracts with us. Our files are kept for the purpose of providing you with investment and insurance products or services that will help you meet your lifetime financial objectives. Access to your personal information is restricted to those employees, representatives and third party service providers who are responsible for the administration, processing and servicing of your contract(s) with us, or any other person whom you authorize. In some instances these persons may be located outside of Canada. You are entitled to consult the information contained in our file and, if applicable, to have it corrected by sending a written request to us. To learn about our Privacy Statement, visit our website at or call SUN-LIFE/ and request that a copy of our Privacy Brochure be sent to you. Access to your information We or our reinsurers may also submit a brief report of our findings to the Medical Information Bureau (MIB), a non-profit organization of life and health insurance companies, which operates an information exchange on behalf of its members. If the person named in this application also applies for insurance coverage or submits a claim with another life or health insurance company that is an MIB member, MIB will, on request, supply that insurance company with the information on its files. To learn about MIB, you may visit the website at call (416) or write to: Medical Information Bureau 330 University Avenue Toronto, Ontario M5G 1R7 You may ask to see your personal information on file with MIB and correct anything that is inaccurate or incomplete. About Sun Life Financial As a leading international financial services organization, we re proud to offer a diverse range of wealth accumulation and protection products and services. Tracing our roots back to 1865, Sun Life Financial has operations in key markets around the world. But most importantly, we re in business to help people achieve and maintain the peace of mind that comes from having sound financial solutions in place. If you d like more information about Sun Life Financial, please visit our website at or call SUN-LIFE/ Please give this page to the proposed insured. E Page 13 of 13 ADMIN1E