Life including Accident & Sickness Agent Application

Life including Accident & Sickness Agent Application Accident & Sickness Agent/Salesperson Application This application applies to individuals who will be transacting Life and/or Accident & Sickness insurance. If you have any questions about this application contact the Life Insurance Council of Saskatchewan or visit our web site. Council s regular business hours are Monday to Friday, 8:00 a.m. to 4:30 p.m. Incomplete Applications any missed items as listed below will be returned without processing. Response to any required information or question. Relevant attachments or supporting documents. Required signatures. Required fees. Application Fees The application fee for obtaining a licence is $100 (please note the licensing fee is subject to change). Please refer to the last page of this application form to obtain the payment options available. If you are using a corporation, partnership, or name other than your personal name, (on business cards, letterhead or any advertising) that corporation, partnership or business name must also be licensed with the Life Insurance Council of Saskatchewan. Submitting Applications All licence applications must be reviewed and signed by your sponsoring insurer prior to forwarding to Council for consideration at: Licensing Department Insurance Councils of Saskatchewan 310 2631 28 th Avenue Regina SK S4S 6X3 Tel: 306.347.0862 www.skcouncil.sk.ca Fax: 306.347.0525

Security Clearance Instructions Criminal record checks must accompany all initial applications for licensing. This applies to first time applicants, individuals who have not held a licence for more than one year or individuals who have to requalify for licensing. Have the local police or RCMP detachment conduct a criminal record check based on a name search. You must apply to the police service that serves the area in which you reside. If a possible record is indicated, you will be required to have this verified by a fingerprint check. The completed original Security Clearance Report must be attached to the application form. The report may not be dated in excess of six months. Any costs associated with the record check are the responsibility of the applicant. Reason for request Insurance Licence Licence issuer Life Insurance Council of Saskatchewan 310 2631 28 th Avenue Regina SK S4S 6X3 Jan 25, 2018

For ICS use only Received Date Receipt No. Life including Accident & Sickness Agent Application, $100 Accident & Sickness Agent/ Salesperson Application, $100 Licence No. Date Issued Part A: Identification Information Mr. Mrs. Miss Ms. Legal Last Name Legal First Name (in full) Legal Middle Name(s) (in full) Preferred first name Maiden name Previous surname(s) Birth Date Sex M M D D Y Y Y Y M F RESIDENCY: Are you, the applicant, a permanent resident or citizen of Canada? No Yes explanation on a separate sheet of paper and attach it to this application form. If No, provide an Place of residence Number and Street, Apt., etc. Personal telephone Personal fax City/Town Province/ State Postal Code/ Zip Code Personal e-mail Address mail will be sent to (complete only if different than place of residence) Business name (if applicable) Business telephone and extension Cell Phone Number and Street, Suite, etc. Business Fax City/Town Province/ State Postal Code/ Zip Code Business e-mail

Part B: Other recognized designations and/or education obtained Please identify the insurance designations you currently hold If you identified the completion of an insurance designation(s), please attach a copy of the applicable certificate(s) or diploma(s) to this application. Highest level of education obtained High School Diploma GED Post Secondary Part C: Background The following are questions relevant to The Saskatchewan Insurance Act regarding trustworthiness and suitability to be licensed. For any questions where you answered yes, or where disclosure is called for, please provide complete details on a separate sheet of paper and attach to the application form. 1. Have you ever held an insurance licence anywhere in Canada, including Saskatchewan, or in another country? No Yes If yes, provide the licence class and jurisdiction. 2. Has any insurance licence held by you, or other licence or registration for selling financial products, ever been suspended or revoked anywhere in Canada, including Saskatchewan, or in another country? No Yes If yes, provide details. 3. Have you ever been refused an insurance licence or other licence or registration for selling financial products anywhere in Canada, including Saskatchewan, or in another country? No Yes If yes, provide details. 4. Are you currently or do you plan to engage in any business or occupation other than the insurance business? No Yes If yes, advise if you are in a supervisory position and provide a detailed job description. 5. Have you ever been the subject of any steps in bankruptcy or receivership? No Yes Note: This includes Consumer Proposals. This question applies to you personally AND also in your capacity as a principal shareholder, officer or director of a company. If yes, provide a copy of the documents filed by your trustee. If a discharge from bankruptcy or other settlement was obtained, provide a copy. 6. Disclose any complaint, investigation or charges against you, past or still pending, for any criminal, quasi-criminal, regulatory or disciplinary offence anywhere in Canada, including Saskatchewan, or in another country. (it is not necessary to report offences dealt with by simply paying a ticket) Nothing to disclose Disclosure attached 7. Disclose any other type of legal action against you, past or still pending, for acts such as mishandling of funds, misrepresentation, fraud, conversion, undue influence or breach of trust. Nothing to disclose Disclosure attached Part D: Agency(s) Representing If you are holding yourself out as representing an agency in the sale of insurance i.e. using business cards, letterhead in the agency name, please identify the agency(s) name. Note: If representing an agency, you must be sponsored by the same insurer sponsoring the agency licence. Part E: Other licensing requirements Errors & Omissions Insurance Attach a copy of your E & O Certificate to this application form. Refer to the bylaws to determine E & O requirements Segregated Funds A licensee may not act as an agent in the sale of segregated funds unless the licensee has passed an investment funds course approved by Council. Please visit the Council web site or contact the office to obtain a current copy of approved courses. I have attached a copy of my certificate of completion or passing examination mark to this application form for one of the approved segregated fund courses.

Part F: Non-resident Applicants 1. I am required to comply with continuing education requirements in my resident jurisdiction. Yes No 2. Have you held an active Life and/or Accident & Sickness Licence for more than two years? Yes No, please provide initial date of life and/or accident and sickness licensing 3. If you have successfully completed the LLQP course and examination, please indicate the name of course provider. 4. a) Saskatchewan Address for Service (As required by Section 421 of The Saskatchewan Insurance Act) Street Address (Box # s not accepted) city/town province postal code 5. a) Jurisdictions that have a web based licensee search. Council will verify the licence status of applicants online; or b) Jurisdictions that do not have a web based licensee search. Applicants must attach an original Certificate of Authority/Non-resident Endorsement from their resident province that is not older than two months. A copy of their licence will not be accepted. 6. Non-residents must provide an original criminal record check not more than six months old. Please refer to page two for details. Part G: Consent to the Collection, Use and Disclosure of Information By applying for an insurance licence or the continuation of my insurance licence, I understand personal information will need to be collected from me and from other sources such as the sponsor of my licence, financial service regulators, law enforcement agencies, credit bureaus, insurance companies, previous employers or other organizations in the financial services sector. I, therefore, consent to the collection and use of this personal information for the purpose of determining my suitability for licensing or the continuation of my licence. I further understand and consent to disclosing personal information to the sponsor of my licence, financial service regulators, law enforcement agencies, credit bureaus, insurance companies or other organizations in the financial services sector, in order determine my suitability for licensing or the continuance of my licence. X Signature of applicant Part H: Declaration The making of a false statement on this application constitutes a material mis-statement and may result in the refusal of this application and the subsequent suspension or cancellation of any licence issued. This application is required to be personally signed by the applicant named herein. I,, solemnly declare that all statements and answers in the foregoing application including attachments are true and correct, and I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath. X Signature of Applicant X Date signed

Part I: Sponsor Declaration To be completed by the licensed insurer sponsoring you. Please Print Applicant s Name is hereby sponsored and authorized to act as an insurance agent Agency(s) representing, if applicable The sponsor certifies that the qualifications and business record of the applicant have been investigated and that the applicant is a trustworthy and competent person to receive a licence. To the best of my knowledge, information and belief, all statements and answers contained in the foregoing application are true and correct. It is understood, if and when this licensee ceases to represent the sponsor named herein, written notice will be given to the Life Insurance Council of Saskatchewan within five days of termination including the reason for termination. THE ABOVE APPLICANT WILL NOT ACT AS AN INSURANCE AGENT UNTIL THE LICENCE IS ISSUED Print Name of Sponsor Authorized Officer Print Name Signature Date M M D D Y Y Y Y Phone number Fax number E-mail address NOTE: NOTE: THE APPLICANT MUST COMPLETE THE ENTIRE FORM PRIOR TO FORWARDING TO YOUR SPONSOR FOR SIGNATURE OF THE SPONSOR DECLARATION. SPONSORS ARE REQUIRED TO REVIEW THE COMPLETED APPLICATION FORM IN ITS ENTIRETY PRIOR TO SIGNING THE SPONSOR DECLARATION.

APPLICANT S ACKNOWLEDGEMENT Print Applicant s Name A licence imposes on the licensee obligations including but not limited to the following: (a) to adhere to the Act, regulations, and bylaws; (b) to follow established standards of competence, conduct and practice in the business of insurance. I acknowledge I have read the Bylaws, and I understand that I am obligated to do the following: To notify Council within 30 days of the commencement of criminal proceedings, legal actions, bankruptcy, name change and/or cancellation of E&O as per Bylaw 2, Section 1, item (4). To submit the Annual Reporting Form and licence fee as per Bylaw 5, Section 2, item (6). To be supervised until I have two years licensed experience as outlined in Bylaws Schedule A, Part II, Section 4, items (1) and (2). Not to act as a supervisor unless I am licensed in Saskatchewan and have at least three years licensed experience as outlined in Bylaws Schedule A, Part II, Section 4, item (3). Not to act in the transaction or supervision of segregated funds unless authorized to do so as outlined in Bylaws Schedule A, Part II, Section 4, item (3). To complete a life insurance replacement declaration (LIRD) prior to replacing an existing life insurance policy as outlined in Bylaws Schedule A, Part II, Section 4, item (4). To maintain Errors & Omissions coverage as outlined in Bylaws Schedule A, Part II, Section 6. To complete the Continuing Education Requirements outlined in Bylaws Schedule B. Part I, Section 1. (1) Licensees are required to earn a minimum of fifteen credit hours of continuing education in each annual reporting period. (2) Only credit hours earned in a reporting period are eligible unless written consent is provided by Council. (3) Failure to comply with the continuing education requirements shall result in a suspension of licence until the licensee has earned the required continuing education credit hours. To obtain continuing education hours through approved course providers and courses that meet the continuing education definition as outlined in Bylaws Schedule B, Part I, Section 2. (1) Only courses that provide technical education are considered to qualify as continuing education including courses that directly relate to: (a) Life or accident and sickness insurance products; (b) Financial planning provided that: (i) a minimum of ten of the fifteen hours required per year is related to life or accident and sickness insurance; and: (ii) a maximum of five of the fifteen hours required per year is related to non insurance sectors such as securities and mutual funds; (c) Compliance with insurance legislation and requirements such as Council s Code of Conduct, Act and bylaws made pursuant to that Act, privacy legislation and anti money laundering and anti terrorist financing legislation; (d) Ethics; (e) Errors and Omissions Insurance; and

Page 2 Licensee Acknowledgment (f) Courses leading to an approved designation such as Chartered Life Underwriter (CLU), Certified Financial Planner (CFP), Registered Financial Planner (RFP), Certified Health Insurance Specialist (CHS), Certified Employee Benefit Specialist (CEBS), Personal Financial Planner (PFP), Certified International Wealth Manager (CIWM), Elder Planning Counselor (EPC) and such other designations as are approved by Council. To complete the Ethics Education Requirement as per Bylaws Schedule B, Part I, Section 1.1. (1) Effective January 1, 2013 all resident licensees must within the cycles set out below complete one or more Life Council approved ethics courses totaling at least three hours in duration: (a) Resident licensees who are licensed on or after January 1, 2013 must complete the ethics training within three years of becoming licensed. (b) Resident licensees who hold a licence issued prior to January 1, 2013 must complete the ethics training by their annual reporting date in 2016. (c) Resident licensees that have completed the course under (a) or (b) above must complete the ethics training within each subsequent 5 year cycle. (d) Credit hours earned for an ethics course can be applied towards a licensee s continuing education requirements. (e) For the purpose of this section each individual ethics course must be at least one hour in duration. To disclose on the initial application for licence and any Annual Reporting Form(s) if I am engaged in, or plan to engage in any business or occupation other than the insurance business. I understand a licence will not be granted in the absence of returning this signed acknowledgment to the Council office. I further understand I am prohibited from acting as an insurance agent until the licence has been granted. Signature of Applicant Date The Life Insurance Council Bylaws, Agent Code of Conduct, The Saskatchewan Insurance Act (pertinent sections 416-446 and Interpretations) and The Saskatchewan Insurance Councils Regulations are posted to the Council website at https://www.skcouncil.sk.ca/lifbylaw.htm for your reference. Oct 2018

Attachments to the application form Details if you have answered yes to Part C A copy of the diploma/certificate of any insurance designation obtained A copy of a completed segregated fund course A copy of E & O Certificate of Insurance The original Non-resident Endorsement, if applicable The original Security Clearance Form The signed and dated Applicant s Acknowledgement Payment of licence fee Oct 4, 2018 Payment information (Please choose a payment option below) or Cheque or money order enclosed for full amount Make cheque or money order payable to the Insurance Councils of Saskatchewan. A NSF charge of $25 will apply for returned cheques. Charge my credit card for the full amount VISA MasterCard - - - Card Number - Expiry Date Signature Print name of applicant Licensing Department Insurance Councils of Saskatchewan 310 2631 28 th Avenue Regina SK S4S 6X3 Tel: 306.347.0862 www.skcouncil.sk.ca Fax: 306.347.0525