Application/Instructions Form Non-registered Savings Annuity (To be used only for companies)
1. Basic information Application/Instructions Non-registered Savings Annuity (To be used only for companies) Language preference: English French Is this: a new application (new plan) OR Instruction Client No: 2. Identification of contractholder Company name (50 characters) Short company name (if applicable) Key activity Work tel. Et. Fa Email address Contact person Email address Tel. Quebec Enterprise Number: numbers 3. Identification of annuitant (mandatory) The annuitant must be an individual and a Canadian resident. Gender: M F Last name First name Home tel. Work tel. Et. Social Insurance No. Date of birth (YYYY/MM/DD) Email address 4. Identification of successor annuitant If no successor annuitant is designated, the contract terminates upon the death of the annuitant. Gender: M F Last name First name Home tel. Work tel. Et. Social Insurance No. Date of birth (YYYY/MM/DD) Email address 5. Beneficiary designation Caution: Complete only if you want the accumulated value to be payable to a beneficiary other than the contractholder. 6. Source of Funds In the event of the annuitant s or, if applicable, the successor annuitant s death Beneficiary s name Relationship to contractholder Date of birth (YYYY/MM/DD) Revocable Irrevocable A cash deposit or an amount already held with the insurer may not be combined with a transfer from another institution. Cash deposit by cheque Date of cheque (YYYY/MM/DD) Transfer from an account held with the insurer Transfer from another institution (Attach copy of statement) Name of financial institution: Address (No., street) Maturity date of investment (YYYY/MM/DD) City Client No. Province Country Postal code La Capitale Insurance and Financial Services Inc. K116 Application/Instructions Non-registered Savings Annuity (09-2013) 1
7. Investment Instructions See rate sheet to learn more about available products. Products Traditional GIC Term Redeemable (R)* Non-redeemable (NR) % R* NR Compound (C) Interest Frequency 1 (A, S, Q, M) Simple (S) Payment 2 (DIA, DD) Equity Inde GIC MAX GIC * R: Redeemable investment subject to the applicable fees and penalties 1. Annual, Semi-annual, Quarterly, Monthly 2. DIA = Daily interest account, DD = Direct Deposit (attach a cheque specimen) 8. Information required under the Proceeds of Crime (Money Laundering) and Terrorist Financing Act Verification of contractholder identity Please attach one of the following documents: The Contractholder s Certificate of Incorporation Etract from a provincial business register A statement confirming the contractholder s eistence Third party involvement Is the Contractholder acting according to the instructions of another person (third party)? Yes No If so, please provide the following information on the third party: Name of third party Date of birth (YYYY/MM/DD) Relationship to contractholder Address (No., Street, Apartment) City Province Postal code Occupation or key activity If the third party is a corporation, please indicate the corporation number and where the corporation certificate was issued. Beneficiaries owners Type of entity: Corporation General partnership Non-profit organization Other (specify): For all persons who directly or indirectly hold or control at least 25% of the shares of the corporation or at least 25% of another type of entity, please specify: Last name, first name Address Title La Capitale Insurance and Financial Services Inc. K116 Application/Instructions Non-registered Savings Annuity (09-2013) 2
8. Information required under the Proceeds of Crime (Money Laundering) and Terrorist Financing Act (cont.) If the contractholder is a corporation, please specify the names and titles of all its directors. Last name, first name Title If the contractholder is a non-profit organization, please provide the following information: - Is the contractholder a charitable foundation that solicits financial contributions from the public? Yes No If so, is the contractholder registered with the Canada Revenue Agency (CRA)? Yes No CRA business No.: 9. AUTHORIZED SIGNING OFFICER (S) Please check the applicable bo. The signing officer(s) who is/are authorized to act for and on behalf of the contractholder is/are the person(s) named in the enclosed resolution. (Please enclose an ecerpt of the relevant resolution from the registers and records of the contractholder.) The signing officer(s) who is/are authorized to act for and on behalf of the contractholder is/are the person(s) named in the resolution anneed to this application. (Please fill out the resolution form anneed to this application.) 10. CONTRACTHOLDER S DECLARATION I have verified the information contained in this application and certify it to be true and complete. I acknowledge that my advisor has provided me with all relevant information about the products applied for, including guaranteed and non guaranteed returns on the amounts invested, the maturity guarantee and applicable fees and penalties. I further acknowledge that my advisor has provided me with satisfactory eplanations in this regard. I understand that the transaction date for a purchase or redemption shall be the business day on which the form is received at the Insurer s office, provided that it is received before 2:00 p.m. EST and it is completed in full, duly signed and submitted with any required amounts. Any form that is received after 2:00 p.m. EST shall be considered to have been received on the following business day. The Insurer reserves the right to change the transaction date without notice. I am applying for a Savings Annuity contract based on this information. Signed at on this day of 20. Signatures numbers Signature of advisor: La Capitale Insurance and Financial Services Inc. K116 Application/Instructions Non-registered Savings Annuity (09-2013) 3
11. Resolution Name of contractholder: Full corporate name BE IT RESOLVED THAT: I, the undersigned,, President and sole shareholder of the above-mentioned company, am the sole person authorized to sign any application, instructions form or document of any nature whatsoever related to any present or future contract underwritten by La Capitale Insurance and Financial Services Inc. Please select one of the options OR The following are the sole persons authorized by the above-mentioned contractholder to sign any application, instructions or document of any nature whatsoever related to any present or future non-registered savings annuity contract underwritten by La Capitale Insurance and Financial Services Inc. Last name Title Signature The signature of only one of these persons is required. OR The signatures of all of these persons are required. CORPORATE SECRETARY S OR PRESIDENT S SIGNATURE (mandatory) I, the undersigned,, Corporate Secretary, President or Corporate Secretary and President of the contractholder hereby certify that the above is a true and eact copy of the resolution adopted by the Board of Directors on the day of 20 and that the resolution is in full force and effect. Signature La Capitale Insurance and Financial Services Inc. 625 Saint-Amable St, Quebec QC G1R 2G5 Telephone: 418 528-2211 or 1 800 463 4433 Email: fim@lacapitale.com La Capitale Insurance and Financial Services Inc. K116 Application/Instructions Non-registered Savings Annuity (09-2013) 4