Application for Annuity Policy

Transcription

1 issued by Transamerica Life Canada Application for Annuity Policy Effective December 2006 managed by CI Investments Inc. issued by Transamerica Life Canada

2 CI Guaranteed Investment Funds CLASS A CLASS B 100 MATURITY/100 DEATH 75 MATURITY/100 DEATH GUARANTEE OPTION GUARANTEE OPTION Front End Deferred Front End Deferred Sales Charge Sales Charge Sales Charge Sales Charge CI Money Market Guaranteed Investment Fund CI Conservative Portfolio Guaranteed Investment Fund CI Moderate Portfolio Guaranteed Investment Fund CI Growth Portfolio Guaranteed Investment Fund CI Aggressive Growth Portfolio Guaranteed Investment Fund CI Harbour Guaranteed Investment Fund CI Harbour Growth & Income Guaranteed Investment Fund CI International Balanced Guaranteed Investment Fund CI Signature Canadian Balanced Guaranteed Investment Fund CI Signature Select Canadian Guaranteed Investment Fund CI Signature Dividend Guaranteed Investment Fund CI Canadian Bond Guaranteed Investment Fund CI Signature High Income Guaranteed Investment Fund

3 Individual Variable Annuity Contract Application Form Effective December 2006 Section 1: CONTRACT TYPE - (Please choose only one) Contract Number Language Preference: English French (If no language preference is indicated, English will be selected.) Non-Registered Plan (Open) Retirement Savings Plan (RSP) Spousal RSP Group RSP Retirement Income Fund (RIF) Spousal RIF Life Income Fund (LIF)* Locked-in Retirement Account or Locked-in RSP (LIRA)* Locked-in Retirement Income Fund (LRIF)* Nominee Open Nominee Registered Nominee Account Number Prescribed Retirement Income Fund (PRIF) *Subject to the terms of the applicable endorsement. Section 2A: OWNER INFORMATION (All contract owners must be Canadian residents.) Title: Mr. Mrs. Miss Ms. Dr. Gender: Male Female Owner Last Name First Name Middle Initial (The Owner is also the Annuitant unless otherwise stated below). Date of Birth (YY/MM/DD) Social Insurance Number Address of Owner City Province Postal Code ( ) Residence Telephone Owner s Occupation Owner s Address RSP Spousal Contributor (To be completed if the contribution is: a) made by spouse, and an official receipt is to be issued to spouse Or b) the rollover of a spousal plan.) Spouse s Last Name First Name Date of Birth (YY/MM/DD) Social Insurance Number Section 2B: JOINT OWNER/SUCCESSOR OWNER/IN TRUST (Non-Registered only) Gender: Male Female Joint Owner with rights of Survivorship (not applicable in Quebec) Date of Birth (YY/MM/DD) Social Insurance Number Successor Owner In Trust Last Name First Name Middle Initial Relationship to Owner Address City Province Postal Code Section 2C: ANNUITANT INFORMATION (Annuitants must be Canadian Resident /For Registered Contracts, the Annuitant must be the Owner.) (Only complete if the Annuitant is different from Owner. For non-registered contracts only. If not completed, the Owner named in Section 2A will be deemed to be the Annuitant.) Title: Mr. Mrs. Miss Ms. Dr. Gender: Male Female (For Non-Registered plans only) Annuitant Last Name First Name Middle Initial c/o CI INVESTMENTS INC. Administration Office CI Place, 151 Yonge Street Eighth Floor Toronto, Ontario, M5C 2W7 Date of Birth (YY/MM/DD) Annuitant Address Relationship to Owner Annuitant s Signature (Required) Social Insurance Number Section 2D: SUCCESSOR ANNUITANT INFORMATION (OPTIONAL) (Must be a Canadian Resident) The successor annuitant takes the annuitant s place if the annuitant dies. As a result, the policy continues. Title: Mr. Mrs. Miss Ms. Dr. Gender: Male Female (For Non-Registered Contracts and RIF Spousal plans only) Successor Annuitant Last Name First Name Middle Initial Date of Birth (YY/MM/DD) Social Insurance Number Address of Successor Annuitant City Province Postal Code Relationship to Owner Section 3: CHOOSE YOUR INVESTMENT(S) Successor Annuitant s Signature (Required) GUARANTEE OPTIONS: CLASS A Maturity/100 Death Guarantees CLASS B - 75 Maturity/100 Death Guarantees Initial deposit of is to be allocated as follows Or RSP/LIRA/RIF/LIF/LRIF/PRIF transfer (T2033/T2151/TD2 attached) to be allocated as follows: Transfer existing Open Contract (Contract Number) to an RSP Account Transfer existing RSP/LIRA (Contract Number) to a RIF/LIF/LRIF/PRIF FUND NAME FUND NUMBER CLASS OPTION A or B DSC Or SALES CHARGE GROSS AMOUNT PERCENT PAC AMOUNT** If no commission method is indicated, the deferred sales charge method will be applied to all Fund except for CI Money Market Guaranteed Investment Fund where the initial sales charge method will be applied. **Minimum of 50 per Fund - Please complete Section 5 and 7 PART 1 - CI COPY PART 2 - AGENT COPY PART 3 - CLIENT COPY

4 Section 4: BENEFICIARY DESIGNATION The Owner reserves the right to revoke the Beneficiary, unless the Beneficiary is irrevocable. The following person(s) is appointed as the beneficiary of the Contract in the event of the death of the Annuitant, if living at the date of that death. For contracts signed in Quebec, if you name your spouse, married or civil, as primary beneficiary, this designation is irrevocable unless you indicate revocable. Once an irrevocable beneficiary has been designated his/her consent will be required for certain dealings with the policy. Share () Irrevocable Beneficiary Yes No Beneficiary s Name Social Insurance Number Relationship to Annuitant Yes No Beneficiary s Name Social Insurance Number Relationship to Annuitant Contingent Beneficiary s Name (optional) Social Insurance Number Relationship to Annuitant Yes No Signature of Irrevocable Beneficiary(ies) if applicable Trustee for the minor beneficiaries (except for Quebec) (MM/DD/YYYY) Last Name First Name Relationship to minor Date of Birth Address City/Province Postal Code Section 5: PRE-AUTHORIZED CHEQUING PLAN (PAC) (Not applicable to LIRAs, LRSPs, RIFs, LIFs, LRIFs, PRIFs) (Please complete Section 7) I/we hereby authorize (Bank Name) to debit my/our account for all amounts payable to: Transamerica Life Canada starting on the (specify the month and day) (MM/DD) into the Fund(s) as indicated in Section 3. Frequency (please choose only one) Monthly Quarterly Semi-Annually Annually I choose to receive plan payment confirmations. (All Owners receive annual statements detailing transactions in their account.) Treatment of each payment shall be the same as if I/we had personally issued a cheque authorizing you to pay as indicated and to debit the amount specified to my/our account. This authorization shall remain in effect until cancellation by written notice to CI Investments Inc. A cancellation notice will be provided at least 48 hours prior to PAC plan debit date. Signature(s) required if Depositor(s) is other than the Owner(s) indicated in Section 2A. Date For a joint bank account, all Depositors must sign if more than one signature is required on cheques issued against the account. Section 6: SYSTEMATIC WITHDRAWAL PLAN & RIF/LIF/LRIF/PRIF PLAN PAYMENT DETAILS (Please complete Section 7) RIF/LIF/LRIF/PRIF Payments: Please accept this authorization to surrender sufficient units to provide the following payment (please choose only one): * This election is irrevocable even in the case of a marriage breakdown or death of my spouse. The minimum annual gross amount *(Payments will begin in the first full calendar year following the initial investment) The maximum annual gross amount (for LIF and LRIF Plans only) An annual amount of Gross or Net of fees and withholding taxes starting on the (1st - 25th) of (specify the month and day). I elect the term of payments to be based on: My age Age of my spouse if younger (Please provide spouse s date of birth in Section 2A) Non-Registered Systematic Withdrawal Payments: Please accept this authorization to surrender sufficient units to provide a payment of Gross or Net of fees starting on (specify the month and day). (MM/DD) Payment Instructions for ALL SYSTEMATIC WITHDRAWAL PLANS (Including RIF/LIF/LRIF/PRIF Plans): Frequency (please choose only one) Monthly Quarterly Semi-Annually Annually Deposit directly to bank account, please complete Section 7 (Bank clearing time for the deposit may vary depending on your financial institution) Mail to Owner Mail to alternate address Name City/Province Postal Code FUND NAME SURRENDER AMOUNT Section 7: BANKING INFORMATION (Please complete for Sections 5 and/or 6 and attach a void cheque.) Bank Account owner(s) Name Bank Name Or PERCENT Bank Transit Number Bank Account Number Section 8: SYSTEMATIC TRANSFER PLAN Please accept this authorization to transfer units from one Fund to another in the same Class, starting on (specify the month and day) (MM/DD) as follows: Frequency (please choose only one) Monthly Quarterly Semi-Annually Annually AMOUNT FROM FUND FUND NUMBER TO FUND FUND NUMBER DSC SALES Or CHARGE (Maximum 2)

5 Section 9: GROUP RSP (Not applicable to LIRA, RIF, LIF, PRIF, or LRIF) Group Company /Association Name Group Plan Number I certify that I am an employee or member of the company or association named above: Employee s/member s Signature Date I (we) hereby authorize the company or association named above to deduct from the employee or member s earnings and remit deposits to the Contract and to assist in the administration of the Contract, in each case as my (our) agent, and to include such deposits in computing the amount of withholding tax required under applicable tax legislation. Owner s Signature Employee s Signature (if other than Owner) Section 10: LIF/LRIF/PRIF INFORMATION SPOUSE: Do you have a spouse within the meaning of the applicable pension legislation? Yes No Note: If you have a spouse within the meaning of the applicable pension legislation, then the form noted on the reverse side of this Application must be fully completed and accompany the Application. Section 11: ACKNOWLEDGEMENT/AUTHORIZATION All Owners must read and sign this section. Acknowledgement By signing below, I (we), the Owner(s), declare that all statements and answers made by me on this Application are fully complete and true. I (we) hereby acknowledge having read the provisions contained in the Notice to Proposed Annuitant and Owner Regarding Establishment of File, contained on the reverse side of this Application, and I (we) hereby agree to them. I (we) have requested that this Application Form be drafted in the English language only. J ai / (nous) demandé (ons) que le présent formulaire de demande soit rédigé en anglais. I (we), the Owner(s), acknowledge receipt of the Information Folder, Annuity Policy and the Summary Fact Statements prior to signing the Application. Owner s Signature Date Signed at Joint Owner s Signature Date Signed at Annuitant s Signature (complete if different from Owner) Date Signature of Witness Will this Contract replace or cause a change in, or involve a loan under, any insurance or annuity policy on the annuitant s life or owned by the Owner? Yes, state company and plan:. No Request for Registration (Must be completed for RSP, LIRA, Locked-In RSP, RIF, LIF, PRIF and LRIF Contracts) I request that Transamerica apply for registration of the contract applied for as a Retirement Savings Plan or Retirement Income Fund under the Income Tax Act (Canada) and under any other applicable provincial income tax legislation. I understand that the Contract will be subject to the provisions of the said Acts and that all payments made out of this Contract will be subject to tax under the provisions of the Acts. If LIRA, Locked-In RSP or LIF, LRIF, PRIF the amount being transferred to the Contract was determined on the basis of the Owner s gender. Yes No Owner s Signature Date Signature of Witness Section 12: DISTRIBUTOR INFORMATION Distributor Name Representative Name Insurance Licence Number Distributor Number Representative Number Address Province of Licence Expiry Date Section 13: IDENTITY VERIFICATION - (To be completed by Representative) By signing here, I hereby declare that I used the following original document to verify the identity of the applicant and that issuing jurisdiction, document number and individual s name appearing therein, as indicated here, were correctly transcribed from such document. I have made reasonable efforts to determine if the Owner and Joint Owner is acting on behalf of a third party. I also declare that I verified the birth date of the Annuitant (and Successor Annuitant, if any) shown above using an original of the same type of document. Owner s Name Document Number Issuing Jurisdiction Driver s Licence Birth Certificate Passport Canadian Citizenship Age of Majority Canadian Armed Forces Identification Joint Owner s Name Document Number Issuing Jurisdiction Driver s Licence Birth Certificate Passport Canadian Citizenship Age of Majority Canadian Armed Forces Identification Verification of Annuitant s/successor Annuitant s Date of Birth Same as Owner, if not Complete Below Individual s Name Document Number Issuing Jurisdiction Driver s Licence Birth Certificate Passport Canadian Citizenship Age of Majority Canadian Armed Forces Identification Are any Owners applying for the Policy on behalf of a third party? Yes No If yes, attach completed CI form OITPDF-10/05 E If Owner is not an individual, complete section B or C of CI form OITPDF-10/05 E and attach. Representative Name Dealer Name Distributor/Representative Number Signature of Representative Date 12/06

6 Disclosure Agent/Advisor Disclosure Statement for the Province of British Columbia The life insurance product you are being offered is issued by Transamerica Life Canada, a company licensed to conduct business in all provinces and territories of Canada. The agent/agency soliciting this insurance application is a licensed life insurance agent representing Transamerica Life Canada and will receive compensation from CI Investments Inc. (on behalf on Transamerica Life Canada) on the completion of this transaction. You are not obligated to transact any other business with Transamerica Life Canada, CI Investments Inc., the agent/agency or any other person or entity as a condition of this application. Notice to Proposed Annuitant and Owner Regarding Establishment of File Upon receipt of this application, CI, on behalf of Transamerica, will establish a file in which will be placed personal information about you concerning (a) this application, (b) any Contract, endorsement, rider or other document issued in connection with this application, (c) other documents or information relating to the investigation, servicing and administration of this application or Contract, and (d) any claim in connection with your file. CI collects personal information about you from this application and any supplementary forms, and from advisors, agents and representatives and other organizations and persons you identify in support of your application. CI and Transamerica uses your personal information for the purposes of underwriting, investigating the information provided in the application, servicing and administering this application and/or Contract, for investigation and administering of claims, and for such other purposes as are specified in this application. Your information may be shared with Transamerica s affiliates and your advisor of record for the purposes identified above. Your Social Insurance Number will be used for income reporting purposes in the context of the administration of your Contract and its benefits. Your banking information will be disclosed to the financial institution(s) processing your pre-authorized deposit plan. You represent and warrant that you are authorized to provide the personal information of any beneficiary named in this application for collection, use and disclosure as described herein. Employees or authorized representatives of Transamerica and CI who will be responsible for functions relevant to the purposes identified above, and other persons authorized by you or by law, will have access to the personal information contained in your file. Subject to exceptions set out in applicable legislation, you may access your file and request corrections to your personal information by sending a written request to Transamerica Life Canada, c/o CI Investments Inc., CI Place, 151 Yonge Street, Eighth Floor, Toronto, ON, M5C 2W7. By completing and signing this application, you consent to the collection, use and disclosure of your personal information as described herein. If a spousal RSP is indicated in this application, you represent and warrant that your spouse has consented to the provision of his/her personal information in this application and to the collection, use and disclosure of his/her personal information as described herein. Spousal Consent/Waiver Forms If the plan being applied for is a LIF or an LRIF, or PRIF, and the Owner has a spouse as defined by applicable pension legislation, then the appropriate form below may be completed. No form is necessary for other provinces or for federally governed plans. Province that governs the plan Name of form Form type British Columbia Spouse s Consent Form 3 (original) Alberta Spouse s Waiver Form 6 Part 1 Option 2 (copy) Saskatchewan Spouse s Waiver Form 1 PRIF (copy) Manitoba Spouse s Waiver Form MG-1701 (copy) Ontario Spouse s Consent Spousal Consent (original) Nova Scotia Spouse s Waiver Form 4 (original) Newfoundland Spouse s Waiver Form 3 (original) ANY AMOUNT THAT IS ALLOCATED TO A SEGREGATED FUND IS INVESTED AT THE RISK OF THE OWNER AND MAY INCREASE OR DECREASE IN VALUE. CITA - AP12/06 E