application for individual life insurance

application for individual life insurance

PRODUCT HIGHLIGHTS Flexible protection at affordable prices TERM 10 - under $100,000 Face value amounts from $25,000-$99,999 Regular underwriting available Issue ages 15 days to 65 years Rates are guaranteed for the life of the contract and will increase only at each renewal Guaranteed renewable, without medical examinations or evidence, every 10 years up to age 75 Convertible to permanent insurance to age 65 TERM 10 - $100,000 and up Face value amounts start at $100,000 Regular and enhanced underwriting available Three underwriting classes Standard, Preferred and Elite Issue ages: Standard/Preferred 18-65 years Elite 35-65 years Rates are guaranteed for the life of the contract and will increase only at each renewal Guaranteed renewable, without medical examinations or evidence, every 10 years up to age 75 Convertible to permanent insurance to age 65 CENTURY LIFE Non-participating, fully-guaranteed term product Face value amounts start at $10,000 Issue ages 15 days to 70 years Face amount paid upon death Guaranteed level premiums, payable to age 100 WHOLE LIFE 100 Non-participating, fully-guaranteed whole life product Face value amounts start at $5,000 Issue ages 15 days to 85 years Face amount paid upon death or survival to age 100 Cash value, benefits and premiums are guaranteed for the life of the contract Waiver of Premium, Accidental Death and Family Term Rider may be added as benefits under any of the above products. INSTRUCTIONS FOR AGENTS PLEASE READ THESE INSTRUCTIONS CAREFULLY 1. FOR PROMPT ISSUE, please be sure all questions are answered clearly and completely. MAKE SURE that all changes to the application are initialled by both the Proposed Life Insured and the Agent. Liquid paper must NEVER be used to make corrections. 2. Please note that ALL of the following conditions must be met before the Temporary Insurance Agreement may be issued: A. The health-related questions are all answered No. B. The Proposed Life Insured is less than 60 years of age. C. The full premium, or one-twelfth of the aggregate yearly premium, is paid. D. The application is for $500,000 or less. 3. MEDICAL INFORMATION BUREAU: Ensure the information stub is detached and given to the Proposed Life Insured at the time the application is written. 4. IMPORTANT INFORMATION REGARDING PRE-AUTHORIZED DEBIT PLAN: Deductions will not commence until the total initial premium has been received. Applicants must complete both Part 1 and Part 2 of the Application for Insurance. 1

APPLICATION FOR INSURANCE PART 1 1. PROPOSED LIFE INSURED First Middle Last Address: Street & No. City/Town Province Postal Code Telephone Numbers: (H) - - (W) - - E-mail Address: Fax Number: - - Date of Birth (DD/MM/YY): Age Last Birthday: Place of Birth: Sex: m M m F Name & Address of Employer: Occupation: Duties: For years 2. POLICY OWNER (Complete the following if the Policy Owner is not the Proposed Life Insured). First Middle Last Relationship to the Proposed Life Insured: Address: Street & No. City/Town Province Postal Code Telephone Numbers: (H) - - (W) - - Date of Birth (DD/MM/YY): Sex: m M m F Contingent Policy Owner - in the event of the death of the above named Policy Owner: First Middle Last Relationship to the Proposed Life Insured 3. U.S. RESIDENCY TAX INFORMATION Tax residency information must be completed by the policy owner. The proposed life insured is also the policy owner if no policy owner is indicated. Are you a US citizen or a US resident for tax purposes? m Yes Please provide your Individual Taxpayer Identification Number (ITIN) or SSN: m No If a contingent policy owner is indicated, please also provide details. Is the contingent policy owner a US citizen or a US resident for tax purposes? m Yes Please provide their Individual Taxpayer Identification Number (ITIN) or SSN: m No 4. BENEFICIARY(IES) First Middle Last Telephone Number Relationship to the Proposed Life Insured % share First Middle Last Telephone Number Relationship to the Proposed Life Insured % share Contingent Beneficiary - in the event of the death of the above named Beneficiary(ies): (optional) First Middle Last Telephone Number Relationship to the Proposed Life Insured Trustee - if Beneficiary is under legal age: First Middle Last Telephone Number Relationship to the Proposed Life Insured 2

APPLICATION FOR INSURANCE - PART 1 (continued) 5. DETAILS OF INSURANCE FOR WHICH PROPOSED LIFE INSURED IS APPLYING Plan: q Century Life q Whole Life 100 q Term 10 : q Regular underwriting* q Enhanced underwriting (available with face amounts of $100,000 or more) *Term 10 - Regular underwriting - If the application is for a face amount of $100,000 or more: You are applying for Term 10 coverage through regular underwriting. In doing so, you have decided not to apply for Term 10 coverage through enhanced underwriting, where you may have been able to qualify for coverage with a lower rate. Face Amount: $ Additional Benefits: Premium Frequency: m Waiver of Premium m Annual bill m Accidental Death $ m Semi-annual bill m Family Term Rider (Complete Family Questionnaire) m Quarterly bill Number of units on: m Monthly pre-authorized debit m Family m Child(ren) only Deduction date: m1 st or m15 th m Other 6. INSURANCE HISTORY & GENERAL INFORMATION FOR PROPOSED LIFE INSURED Please provide full details of all Yes answers and complete appropriate form(s) where indicated. Attach additional sheets if necessary. a) Is there any existing insurance on your life? If yes, give details below: m Yes m No Name of Company Amount Date of Issue Accidental Death Benefit Amount b) Is this insurance intended to replace, change or modify any existing life insurance policies or policy cancelled within the last six (6) months? (Not including employer-sponsored group policies.) If yes, complete a Life Replacement Declaration form. m Yes m No c) Has any application for life insurance or for reinstatement or renewal of a policy ever been declined, postponed, rated or modified in any way? m Yes m No If yes, provide date and details: d) Are there any other applications for life insurance pending or contemplated? m Yes m No Total amount of pending insurance to be placed with all other companies $ e) Have you used tobacco in any form, used any nicotine replacement products or used hashish or marijuana: i) within the last 12 months? m Yes m No ii) within the last three (3) years? m Yes m No iii) within the last five (5) years? m Yes m No If yes, state type and amounts: f) In the past five (5) years, have you: i) been convicted of reckless driving or driving under the influence of drugs or alcohol? m Yes m No ii) had your driver s licence suspended or revoked? m Yes m No iii) had two (2) or more moving violations? m Yes m No If yes, provide date, details and driver s licence number: 3 g) In the past two (2) years, have you engaged in or do you plan to engage in risky activities such as hang gliding, sky diving, scuba diving, auto or motorcycle racing, rock climbing, helicopter skiing or any other similar activity? m Yes m No If yes, provide date and details:

APPLICATION FOR INSURANCE - PART 1 (continued) h) Other than as a fare-paying passenger, do you intend to fly or have you flown any type of aircraft in the past two (2) years? m Yes m No i) Have you ever been charged with or convicted of any criminal offence or are any such charges pending? m Yes m No If yes, provide date and details: j) Do you plan to spend more than one month outside of North America or Western Europe in the next 24 months? m Yes m No If yes, provide date and details: APPLICATION FOR INSURANCE PART 2 1. Height: ft in OR cm Weight: lbs OR kg Have you lost more than 10 lbs or 4.5 kg in the last 12 months? m Yes m No Reason: 2. Family History Age if Living Current Health Condition Age at Death Cause of Death If not good, state reason Father Mother Brothers & Sisters Have any of your parents, brothers or sisters ever had heart disease, high blood pressure, stroke, polycystic kidney disease, Huntington s Chorea, multiple sclerosis, diabetes, cancer or other inheritable disease? m Yes m No If yes, please provide details: 3. Name of your family physician, medical advisor or clinic: Date and reason of your last appointment: What was the treatment given or medication prescribed? 4. Are you currently experiencing symptoms or problems that require medical attention? m Yes m No If yes, provide details: 5. Are you aware of any symptoms or complaints regarding your health for which you have not yet consulted a physician or received treatment? m Yes m No If yes, provide details: 6. Are you currently taking any prescription medicine? m Yes m No If yes, provide details: 7. In the last 12 months, has a medical professional advised you to either see another doctor, or have a surgical operation or diagnostic test that is not yet completed or for which the results are still not known? m Yes m No If yes, provide details: 4

APPLICATION FOR INSURANCE - PART 2 (continued) Please provide details for all Yes answers on next page 8. Have you ever been treated for or had any known indication of: a) Chest pain, high blood pressure, heart murmur, palpitations, angina, heart attack, elevated cholesterol or any problems with the heart, veins or blood circulation? m Yes m No b) Asthma, bronchitis, persistent hoarseness, blood spitting, emphysema, shortness of breath, sleep apnea or other respiratory disorder? m Yes m No c) Disease or disorders of the eyes, ears, nose, throat or skin? m Yes m No d) Depression, anxiety or any other mental or psychological disorder? m Yes m No e) Dizziness, fainting, recurrent headaches, convulsions, stroke or mini-strokes or other disorder of the neurological system? m Yes m No f) Ulcers, jaundice, hepatitis, colitis, Crohn s, chronic diarrhea, liver disease, intestinal bleeding or other gastrointestinal disease or disorder of the bowel? m Yes m No g) Arthritis, lupus, amputations or any problems with the joints, spine, muscles, bones, back or neck? m Yes m No h) Albumin (protein), sugar, blood or pus in the urine, prostate problems, any other kidney or urinary disorder or any disorder of the breast or reproductive organs? m Yes m No i) Cancer, tumour or other malignant disease? m Yes m No j) Diabetes, thyroid disorder, anemia, hemophilia, enlargement of the lymph nodes or any other disorder of the blood, the lymph glands or other glands? m Yes m No 9. Have you ever: a) been told you have or been diagnosed with AIDS, ARC (AIDS Related Complex) or other immunological disorder? m Yes m No b) tested positive for exposure to the AIDS virus? m Yes m No 10. Within the past five (5) years, have you: a) undergone any diagnostic testing such as an ECG or X-ray? m Yes m No b) seen a specialist? m Yes m No c) been a patient in a hospital, clinic or other medical facility? m Yes m No 11. Have you ever been unable to work on a full-time basis of at least 20 hours a week for an employer? m Yes m No If yes, state reason and duration of absence: 12. Have you ever undergone or been advised to get treatment, counselling or hospitalization for alcoholism, excessive alcohol use or have you ever attended Alcoholics Anonymous? m Yes m No If yes, provide details: 13. Current Alcohol Usage: m None # Drinks per m Day m Week m Month 14. In the last 10 years, have you used cocaine, heroin, ecstasy or other narcotics, hallucinogens, barbiturates, amphetamines or other illegal, mood-altering drugs? m Yes m No If yes, provide details: 5

APPLICATION FOR INSURANCE - PART 2 (continued) Please provide details for all Yes answers (date, duration, results and name of doctors). AUTHORIZATION I, the undersigned, declare the answers to the above questions are complete and accurate and form part of an application for coverage with Blue Cross Life Insurance Company of Canada (Blue Cross Life) and/or Medavie Blue Cross. The information provided herein and collected in the future as part of the application process will be kept confidential and secure. This information will be used to determine eligibility for coverage, to administer the terms of my policy, to recommend suitable products and services to me and to manage the Company s business. I authorize any physician, pharmacy, health practitioner, hospital, clinic or other medical or medically related facility, insurance company, government or regulatory authority, MIB, Inc. formally known as Medical Information Bureau or other organization, institute or person that has any records or knowledge of me or my health, to give Blue Cross Life, Medavie Blue Cross or their reinsurer any such information. I further authorize Blue Cross Life and Medavie Blue Cross to disclose this information to each other, their reinsurer or to any third party when required to determine eligibility of the application. Medical information may also be released to my personal physician or other medical practitioner. I also authorize Blue Cross Life and Medavie Blue Cross to make a brief report of my personal health information to MIB. This consent is valid for as long as the contract is in force, unless I revoke it in writing. I understand I may revoke my consent at any time; however, if consent is withheld or revoked the coverage may be denied or rescinded. I understand why my personal information is needed and am aware of the risks and benefits of consenting or refusing to consent. I have received and read the attached notice form describing the procedures of MIB. I can contact Medavie Blue Cross at 1-800-667-4511 should I have questions as to the collection, use or disclosure of my personal information. This consent complies with federal and provincial privacy laws. A photocopy of this consent is as valid as the original. Date Proposed Life Insured (if under 16, signature of parent/guardian) Witness (other than beneficiary) 6

DECLARATION AND AGREEMENTS 1. I affirm I am applying to Medavie Blue Cross and Blue Cross Life for the insurance described here and I declare and agree: a) No person has authority to modify or waive any part of this agreement. b) Acceptance of the policy constitutes approval of its provisions and ratification of any additions or endorsements or amendments. c) Coverage will begin when the policy is delivered to me while I am still in the same state of health as when coverage was applied for and the first premium has been paid to Medavie Blue Cross and Blue Cross Life. 2. I understand Medavie Blue Cross and Blue Cross Life reserve the right to request additional medical evidence in underwriting this application. 3. I agree if any evasion, concealment or misrepresentation of a fact material to the risk is contained herein (including misstatement of smoking status), any life insurance arising from this application shall be null and void. 4. I have read the entire contents of this application form and acknowledge all statements and answers made in this application form, including Part 1, Part 2 and any supplementary applications or forms, are true and complete to the best of my knowledge. 5. I understand the language in which this application is written. The details of this application have been fully explained to me and are completely understood. 6. In the event of death and upon request by Medavie Blue Cross or Blue Cross Life, the Policy holder, Beneficiary or Estate Administrator is expressly authorized to provide information to permit analysis and justification of the claim. Dated at in the province of this day of year Proposed Life Insured Policy Owner Witness (other than beneficiary) (if under 16 - signature of parent/guardian) (if different from Insured) TEMPORARY INSURANCE HEALTH QUESTIONS 1. Has the Proposed Life Insured: a) ever had any known indication of, or treatment for, any of the following: heart or blood vessel disease (including treatment of high blood pressure), stroke, chest pain, cancer or tumours? m Yes m No b) had any symptoms or treatment for any medical condition that resulted in hospitalization within the last two (2) years? m Yes m No c) ever applied for and/or received life insurance which was rated, declined or modified in any way? m Yes m No 2. Is the Proposed Life Insured aware of any special tests or investigations which have not yet been completed or for which the results are still not known? m Yes m No I have read the Temporary Insurance Agreement, I understand it, I am under the age of 60 years on this day and I agree to its terms. Date Proposed Life Insured (if under 16, signature of parent/guardian) 7 Witness (other than beneficiary) Policy Owner (if different from Insured)

METHOD OF PAYMENT A: Direct Billing: Annual Semi-annual Quarterly B: Monthly Pre-authorized Debit (PAD): 1st 15th Please complete the Pre-authorized Debit (PAD) plan agreement below. I/We authorize Medavie Blue Cross and the financial institution designated (or any other financial institution I/we may authorize at any time) to begin deductions as per my/our instructions for recurring payments and/or one-time payments from time to time, for payment of insurance premiums. Regular monthly payments for the full amount of services delivered will be debited to my/our specified account on the day of the month indicated above. Medavie Blue Cross will not provide monthly pre-notification but will provide 30 days notice if the deduction is subject to change. Medavie Blue Cross will obtain my/our authorization for any other one-time or sporadic debits. Medavie Blue Cross requires written notification of any changes to banking information. This authority is to remain in effect until Medavie Blue Cross has received written notification from me/us of its change or termination. This notification must be received at least 30 business days before the next debit is scheduled. This notification must be sent to the Administration department of Medavie Blue Cross. I/We may obtain a sample cancellation form or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting www.cdnpay.ca. I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD Agreement. To obtain a form for a Reimbursement Claim, or for more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca. Type of Service: Personal Business Please attach a void cheque. (Credit card payments are not accepted.) Financial Institution (FI): (PLEASE PRINT) Address: City/Town: Province: Postal Code: FI Transit Number: FI Account Number: (transit - 5 digits; FI - 3 digits) DATE: Authorized Signature(s): If someone other than the Policy Owner will be paying the premiums, please have them sign and date above and complete their personal information below: Address: City/Town: Province: Postal Code: Phone Number: (Bus.) - - (Res.) - - AGENT S REPORT 1. a) How long have you known the Proposed Life Insured? b) Is he/she related to you? m Yes m No 2. Approximate net worth of the Proposed Life Insured: $ Annual earned income: $ Other Income: $ Source: Information based on Proposed Life Insured statement m or your estimate m 3. What is the principal purpose of this insurance? 4. Please show details of premium calculation: a) Age at issue b) Male or Female c) Smoker or Non-smoker d) Rate per $1,000 of basic policy $ - WP $ - AD $ - Family Rider $ e) Total per $1,000 $ f) Policy Fee $ g) Annual Premium $ h) Contractual premium to be paid $ 8

AGENT S REPORT (continued) 5. Amount received from the applicant: $ 6. Was the Temporary Insurance Agreement (TIA) completed and given to the Insured? m Yes m No 7. If additional underwriting requirements are necessary, what has been arranged? (The following requirements are the Agent s responsibility to request.) m Paramedical m Medical m ECG m Blood chemistry profile m Saliva test Expected date of completion: 8. If Proposed Life Insured is a child: a) How much insurance does the Insured (Policy Owner) have on his/her life? b) How much insurance do the brothers and sisters of the child have on their lives? 9. If Proposed Life Insured is not self-supporting: a) How much insurance does the supporting person have on his/her own life? b) If less than the coverage applied for on the Proposed Life Insured, state why: 10. Insured s (Policy Owner s) language of choice: m English m French If not indicated, the language of the application will be used. 11. By signing below you confirm that you, the agent, have disclosed: a) the company or companies you represent; b) that you receive commissions for the sale of life and health insurance company products; c) that you may receive additional compensation in the form of bonuses, conference programs or incentives; and d) any conflicts of interest you may have in respect to this transaction. Agent s PLEASE PRINT Agent s Address: Agent s Number: Phone Number: Fax Number: E-mail: Signature: 9

TEMPORARY INSURANCE AGREEMENT AND RECEIPT Medavie Blue Cross and Blue Cross Life agree to provide interim insurance of $ on the life of the Proposed Life Insured named in Part 1 of the application made on the date of this Agreement, payable on the death of the Proposed Life Insured to the Beneficiary named in Part 1 subject to the following conditions: 1. There will be interim insurance on the Proposed Life Insured only if he or she is under the age of 60 years on the date of this Agreement. 2. Interim insurance will be effective only if each of the Temporary Insurance Health Questions (page 7) is properly answered No by the Proposed Life Insured. 3. The amount of interim insurance provided is the lesser of: (A) the amount applied for under the Basic Plan shown in Part 1, or (B) $500,000. 4. Insurance under only one Temporary Insurance Agreement can be in effect on the Proposed Life Insured at any one time. 5. No interim insurance is provided: (A) under any additional benefits applied for. (B) in case of suicide. 6. At least one-twelfth of the aggregate yearly premium for the amount of the Basic Plan and Term Riders must have been paid to Medavie Blue Cross at the time of the completion of Part 1. 7. Interim insurance terminates automatically when a policy providing insurance under the Basic Plan becomes effective. 8. Medavie Blue Cross and Blue Cross Life may terminate interim insurance by mailing a notice to that effect, addressed to the Insured (termination being effective on mailing), in which event any money paid will be refunded. 9. In any event, interim insurance will terminate automatically on the expiration of 90 days from the date of this Agreement. 10. The printed terms of this Agreement may not be altered. It is acknowledged that the sum of $ Part 1. was paid to Medavie Blue Cross at the time of the completion of Dated: Countersigned: Agent Authorized signatory of the Board of Directors RECEIPT (To be completed if the Proposed Life Insured does not qualify for temporary insurance coverage). Medavie Blue Cross acknowledges receipt of $ paid in connection with the application for life insurance on the life of. This receipt ackowledges that the sum referred to above has been received on behalf of Medavie Blue Cross and NO INSURANCE COVERAGE EITHER EXPRESSED OR IMPLIED is conveyed by the acceptance of such sum. The Proposed Life Insured hereby acknowledges and agrees that THERE IS NO INSURANCE COVERAGE resulting from the acceptance of the money and that Medavie Blue Cross and Blue Cross Life are not at risk unless, and until, a contract comes into effect as a result of this application. Date Witness (other than beneficiary) Insured (Policy Owner) Proposed Life Insured MIB PRE-NOTICE Information regarding your insurability will be treated as confidential. Blue Cross Life or its reinsurers may make a brief report thereon to MIB, Inc, a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life, disability or health coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with information it has in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it has in your file. To question the accuracy of information in MIB s file, you may contact MIB and seek a correction. The address of MIB s information office is: MIB, Inc. Telephone: 416-597-0590 330 University Avenue, Suite 501 Website: www.mib.com. Toronto, Ontario M5G 1R7 Blue Cross Life or its reinsurers may also release information in its file to other life insurance companies to which you may apply for health or life insurance or to whom a claim for benefits may be submitted. Please detach and retain 10

life insurance for everyone TM The Blue Cross symbol and name are registered trademarks of the Canadian Association of Blue Cross Plans, used under licence by Medavie Blue Cross, an independent licensee of the Canadian Association of Blue Cross Plans. * Trade-mark of the Canadian Association of Blue Cross Plans. Trade-mark of Blue Cross Blue Shield Association. FORM-104E 04/16