1. Your Health Application for Whole Life Insurance Underwritten by Western Life Assurance Mail Application to: Everest Team, 5150 Spectrum Way, Suite 500, Mississauga, ON L4W 5G2 1 800 913 8318 ENSURE THE APPLICANT INITIALS ALL CHANGES. NO CORRECTION FLUID SHOULD BE USED. SIMPLIFIED ISSUE APPLICATION FORM Insurance is a contract based on trust. Failure to disclose facts, material to this application, could make your contract void. 1. Within the past THREE (3) years, have you been told you had, been diagnosed with, or received treatment for: stroke; heart disease or disorder (such as heart attack, angina, severe/persistent chest pains or congestive heart failure); cancer; leukemia; emphysema; kidney failure; diabetes requiring daily insulin; cirrhosis of the liver or chronic hepatitis; immune system disorder, or tested positive for the human immune deficiency virus (HIV), or been diagnosed as having AIDS related complex (ARC), or AIDS; mental or nervous system disorder, including Alzheimer s, Parkinson s, multiple sclerosis, cerebral palsy or suicide attempts? 2. Within the past THREE (3) YEARS, have you received treatment for alcohol or drug abuse or been advised by a physician to reduce alcohol consumption due to alcohol abuse? 3. Within the past THREE (3) YEARS, have you had any life insurance application denied? 4. Within the past THREE (3) YEARS: If employed have you been unable to work for four (4) or more consecutive weeks due to illness or an accident? If not employed have you been a patient in a hospital/extended healthcare/nursing home facility for four (4) weeks or longer? For individuals age 18-80 inclusive who answered No to all of the health questions, please proceed. 2. Select Your Coverage $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 3. About You Date of Birth: Gender: Male Female Month Day Year Full Legal Name: First Name Middle Name Last Name Mailing City Province Postal Code Home Phone Number (Including Area Code) 4. I confirm that I can read and speak English:. If No, please complete and attach the Interpreter s Statement. Form #WLA 00050 12-2014 5. I confirm that I am only a tax resident of Canada or a tax resident of Canada and the United States:. If No, you will be contacted by Western Life Assurance for additional information. 6. Your Beneficiary (Required) 7. Payment Type (Select only one): Monthly Payments Single Payment (Client identification form required) Only available on $5,000 and $10,000 coverage amounts. Note: If more than one beneficiary is designated, the beneficiaries will share equally in the life insurance benefit, unless otherwise specified. If a minor is named as beneficiary without an appointed trustee, a public trustee may be required to receive the proceeds. Fund payment may be delayed or paid to the courts. Signature of Cardholder or Cheque Account Holder - (Required if other than Applicant) Payment Options (Select only one): Pre-Authorized Chequing - Attach a cheque marked VOID (only VOID cheques accepted) Credit Card Visa MasterCard (We do not accept Visa Debit or Visa Prepaid Cards) Card Number: Expiry Date (MM/YY): Cardholder s Name (Exactly as it appears on the card) Mailing (Required if other than applicant) City Province Postal Code Payment Amount and Date I understand that the effective date of this insurance policy will be on the date I enter below, provided that my first month s premium has been paid. ** You may not select a payment date that is more than 30 days from the date of your signature on the next page. I authorize monthly payments in the amount of $ for premium plus applicable taxes to be debited to the account or charged to the credit card. I request that payments begin on and continue on approximately the same day of each month thereafter. Month / Day ** I understand that the initial payment may be debited after this date due to time required for administrative processing, and in the event that occurs, monthly payments thereafter will be on or near the day of the month I have selected. This plan is only available to residents of Canada excluding Quebec. Form #WLA 00049 06-2017 C
Declaration and Authorization 1. I declare that I am legally authorized to reside in Canada and reside within the country at least 6 months a year. 2. I declare that all information and statements in this Simplifed Issue Application Form and any questionnaire or declaration of insurability made in connection with this application are, to the best of my knowledge and belief, true, accurate and complete. 3. I understand and agree that Western Life Assurance is relying on the information and statements provided to consider my application for insurance and to determine whether to issue a policy and that in the event of false or misleading information or statements, any issued policy shall be NULL and VOID. Should my health change at any time between the date of this application and the effective date of my insurance I must contact Western Life Assurance who will determine whether I am still eligible for coverage and a failure to do so may result in any issued policy being NULL and VOID. 4. I declare and understand that this application by me is not intended to replace or change any existing life insurance or annuity policy. 5. I understand that if I die from self-inflicted injuries, while sane or insane, within two (2) years from the effective date or date of the most recent reinstatement, the amount of insurance will be limited to all premiums paid since such date. I understand that if I die within these first two years, defined as the contestability period, Western will investigate the details of my medical history to confirm that I accurately answered all health questions on this application. Western also reserves the right to request medical information after the two year period if for any reason they believe I may have failed to fully disclose my medical history. 6. I understand that coverage begins only after approval of my application by Western Life Assurance and then only if the first premium is paid in full and honoured by the Financial Institution. 7. Authorization I understand that premiums are a level amount as stated in my policy contract and the premum amount does not include applicable sales or other taxes. I also understand that in certain instances, such as a returned cheque or missed premium, that the premium can be increased to cover the fees and missed past premiums. In the event of an unsuccessful payment, a $35.00 fee will apply. I agree that this authorization in no way affects the terms or conditions of the policy. This authorization shall continue in force so long as said policy shall qualify for premium payments under this plan or until this authorization is revoked. Either party to this agreement may terminate this authorization by written notice mailed to the other party at his address of record. a. If the Pre-Authorized Payment Plan has been selected... Western Life Assurance is requested and authorized to draw cheques under its Pre-Authorized Payment Plan on the Account and Financial Institution designated by me. I further authorize such institution and any of its branches to deal with such transfers as though they were signed by me. I also agree to furnish Western Life Assurance with a voided blank cheque now and at any future time, as required, to assure the accurate imprinting of bank information on my Pre-Authorized transfers. I may revoke my authorization at any time, subject to providing 30 days notice. To obtain a sample cancellation form, or for more information on my right to cancel a PAP Agreement, I may contact my financial institution or visit www.cdnpay.ca Every effort will be taken to meet the same date every month, however this date could change for a given month. Western Life Assurance is not required to provide notification before the initial premium is debited. I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with this preauthorized payment (PAP) Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca b. If the Credit Card Payment Plan has been selected... Western Life Assurance is requested and authorized to charge my Credit Card. I agree to furnish Western Life Assurance with the updated Credit Card Expiry date as required. This authorization extends to any replacement cards I may receive and will remain in effect until I cancel it. c. Personal Information Notice and Authorization: The information collected on this application for insurance is required for the purposes of considering and if approved, processing my application for insurance and to administer any insurance, the Everest funeral planning and family support assistance benefit and to investigate claims. This information and information in my customer file, may be used by and exchanged among Western Life Assurance, its agents, Everest, reinsurers and authorized administrators for these purposes or as other-wise authorized or required by law. This information may be processed and stored in the United States and may be accessible to the United States government, courts or law enforcement or regulatory agencies through the laws of the United States. From time to time Western Life Assurance or Everest, or either of their approved partners may also use this information to offer me additional products and services but my consent to the use of my information for this additional purpose is optional. If I wish more information about Western Life s personal information handling practices I may write to Western Life Assurance at P.O. Box 3300, Winnipeg MB R3C 5S2, e-mail privacy@westernlife.com or call 1-888-647-5433. For purposes of processing my application for insurance and administering claims, I hereby authorize any physician, practitioner, health care provider, hospital, health care institution, medical organization, clinic and any other medical or medically related facility, government office or provincial health insurance plan, insurance company, workers compensation board or similar plan or organization, to release and exchange with Western Life Assurance, personal health information. This authorization shall take effect on the date it is signed and it shall expire seven years after the termination of any policy issued as a result of this application. I understand that I may revoke this consent at any time but if I do, Western Life Assurance may be unable to process my application for insurance or administer the insurance or claims related to a policy, if issued. The present consent, declaration and authorization is valid for the purposes of the present contract, its modifications, extension or reinstatement. A photocopy of this consent shall be as valid as the original. By signing below, I confirm I am the applicant listed in the About You section of this form, that I am legally authorized to reside in Canada and reside within the country at least six months a year. I further confirm that all information and statements in this application and any questionnaire or declaration of insurability made in connection with this application are, to the best of my knowledge and belief, true, accurate and complete. If my tax residency status should change in the future, I will inform Western Life Assurance within 30 days of the change. I further confirm I understand that I am purchasing a whole life insurance policy and that the proceeds of a claim on this policy can be used at the discretion of my beneficiary and/or estate and I understand that the Everest Concierge Service is included as a benefit of the whole life insurance policy I am purchasing. Signed at, this day of, (City) (Province) (Month) (Year) Applicant s Signature AGENT S INFORMATION Agent s First Name Agent s Last Name Agent s First Name Agent s Last Name A G E N T City Your SMD s Name Province A G E N T City Your SMD s Name Province 1 Agent s Code 2 Agent s Code Page 2 - Simplified Issue Application Form
PREMIUM RATES FOR WESTERN LIFE SIMPLIFIED ISSUE WHOLE LIFE INSURANCE Version 06-2017 Monthly Payments ($) FEMALE AGE* 5,000 10,000 15,000 20,000 25,000 30,000 5,000 10,000 15,000 20,000 25,000 30,000 18 20 30 33 40 47 54 22 31 36 44 52 60 19 21 30 33 40 47 54 22 32 36 44 52 60 20 21 30 34 41 48 55 22 32 36 44 52 60 21 21 30 34 41 48 55 22 32 37 45 53 61 22 21 31 34 41 48 55 23 33 37 45 53 61 23 22 31 36 44 52 60 23 33 38 46 54 62 24 22 32 36 44 52 60 23 34 38 46 54 62 25 22 32 36 44 52 60 24 34 39 48 57 66 26 23 32 37 45 53 61 24 34 40 49 58 67 27 23 33 37 45 53 61 24 35 40 49 58 67 28 23 33 38 47 56 65 25 35 41 50 59 68 29 24 33 39 48 57 66 25 36 41 50 59 68 30 25 34 39 48 57 66 25 36 42 52 62 72 31 25 34 40 49 58 67 26 37 43 53 63 73 32 25 35 40 49 58 67 26 37 43 53 63 73 33 26 35 41 51 61 71 26 38 44 54 64 74 34 26 35 42 52 62 72 27 38 46 57 68 79 35 26 36 42 52 62 72 27 39 46 57 68 79 36 26 36 43 53 63 73 27 40 47 58 69 80 37 27 37 43 53 63 73 28 40 47 58 69 80 38 27 37 44 55 66 77 28 41 49 61 73 85 39 27 38 45 56 67 78 28 41 49 61 73 85 40 27 38 45 56 67 78 29 42 50 62 74 86 41 28 39 46 57 68 79 29 43 51 63 75 87 42 28 39 46 57 68 79 30 44 52 65 78 91 43 29 40 48 60 72 84 30 45 53 66 79 92 44 29 41 49 61 73 85 31 45 55 69 83 97 45 29 42 49 61 73 85 31 46 56 70 84 98 46 30 42 50 62 74 86 32 47 58 73 88 103 47 30 43 52 65 78 91 32 48 59 74 89 104 48 31 44 52 65 78 91 33 49 60 76 92 108 49 31 44 54 68 82 96 34 50 61 77 93 109 50 31 45 55 69 83 97 34 51 63 80 97 114 51 32 46 56 70 84 98 35 52 64 81 98 115 52 33 47 58 73 88 103 36 53 67 85 103 121 53 33 48 59 74 89 104 36 55 68 86 104 122 54 34 49 61 77 93 109 37 56 70 89 108 127 55 34 50 62 78 94 110 38 57 71 90 109 128 56 35 52 64 81 98 115 39 59 74 94 114 134 57 36 53 66 83 100 117 40 61 77 98 119 140 58 37 55 68 86 104 122 40 63 79 101 123 145 59 37 56 70 89 108 127 41 65 82 105 128 151 60 38 58 73 93 113 133 42 66 85 109 133 157 61 39 60 76 97 118 139 44 69 88 113 138 163 62 40 62 78 100 122 144 45 71 91 117 143 169 63 41 64 80 102 124 146 46 73 94 121 148 175 64 43 65 83 106 129 152 47 75 97 125 153 181 65 44 67 86 110 134 158 48 78 100 129 158 187 66 45 71 90 115 140 165 50 81 105 135 165 195 67 46 74 94 120 146 172 52 85 110 142 174 206 68 48 77 98 125 152 179 53 89 115 148 181 214 69 49 81 102 130 158 186 55 93 120 155 190 225 70 50 84 107 137 167 197 56 97 125 161 197 233 71 53 90 114 146 178 210 59 103 132 170 208 246 72 55 95 120 153 186 219 62 108 140 180 220 260 73 58 100 126 160 194 228 64 114 147 189 231 273 74 60 106 133 169 205 241 67 120 155 199 243 287 75 62 111 140 178 216 254 70 126 163 209 255 301 76 66 119 150 190 230 270 73 134 172 220 268 316 77 70 126 160 203 246 289 77 142 181 231 281 331 78 74 134 170 216 262 308 81 150 192 245 298 351 79 77 142 179 227 275 323 85 158 202 258 314 370 80 81 149 188 238 288 338 89 166 212 271 330 389 MALE * Age means age on the date coverage begins. Rates subject to change prior to purchase.
PREMIUM RATES FOR WESTERN LIFE SIMPLIFIED ISSUE WHOLE LIFE INSURANCE Version 06-2017 Single Payments ($) * Age means age on the date coverage begins. Rates subject to change prior to purchase. FEMALE MALE AGE* 5,000 10,000 5,000 10,000 18 3,181 4,480 3,337 4,701 19 3,203 4,521 3,358 4,742 20 3,233 4,566 3,395 4,796 21 3,283 4,630 3,446 4,857 22 3,334 4,694 3,497 4,917 23 3,377 4,733 3,555 4,988 24 3,427 4,797 3,606 5,048 25 3,477 4,861 3,657 5,109 26 3,541 4,941 3,721 5,186 27 3,611 5,017 3,792 5,274 28 3,675 5,098 3,855 5,351 29 3,745 5,189 3,926 5,439 30 3,608 5,269 3,780 5,516 31 3,634 5,312 3,816 5,581 32 3,660 5,370 3,851 5,646 33 3,687 5,412 3,886 5,712 34 3,713 5,470 3,922 5,777 35 3,739 5,528 3,957 5,843 36 3,765 5,571 3,992 5,908 37 3,792 5,629 4,028 5,974 38 3,818 5,673 4,063 6,040 39 3,845 5,731 4,098 6,106 40 3,871 5,774 4,134 6,172 41 3,910 5,832 4,176 6,235 42 3,948 5,890 4,218 6,299 43 3,987 5,962 4,260 6,364 44 4,025 6,020 4,302 6,429 45 4,063 6,079 4,344 6,494 46 4,102 6,137 4,386 6,559 47 4,141 6,196 4,428 6,625 48 4,179 6,256 4,470 6,691 49 4,218 6,315 4,513 6,758 50 4,256 6,375 4,555 6,825 51 4,299 6,483 4,605 6,950 52 4,341 6,591 4,655 7,075 53 4,384 6,713 4,705 7,200 54 4,426 6,821 4,755 7,325 55 4,468 6,930 4,805 7,450 56 4,523 7,030 4,856 7,544 57 4,578 7,130 4,907 7,638 58 4,633 7,230 4,958 7,732 59 4,688 7,317 N/A 7,825 60 4,743 7,416 N/A 7,917 61 4,813 7,573 N/A 8,065 62 4,882 7,717 N/A 8,212 63 4,952 7,873 N/A 8,359 64 N/A 8,018 N/A 8,505 65 N/A 8,174 N/A 8,652 66 N/A 8,387 N/A 8,865 67 N/A 8,596 N/A 9,072 68 N/A 8,799 N/A 9,274 69 N/A 9,009 N/A 9,472 70 N/A 9,204 N/A 9,665 71 N/A 9,430 N/A 9,826 72 N/A 9,703 N/A N/A 73 N/A N/A N/A N/A 74 N/A N/A N/A N/A 75 N/A N/A N/A N/A 76 N/A N/A N/A N/A 77 N/A N/A N/A N/A 78 N/A N/A N/A N/A 79 N/A N/A N/A N/A 80 N/A N/A N/A N/A www.everestfuneral.ca
THE EVEREST PACKAGE EXCLUSIVELY OFFERED THROUGH WFG Who do you know that could benefit from Everest? CLIENT S NAME DATE OF REFERRAL REFERRALS 1 First and Last Name Telephone Email 2 First and Last Name Telephone Email 3 First and Last Name Telephone Email 4 First and Last Name Telephone Email