Application for Conversion Non-Underwritten This form is for use with simple conversions that do not require evidence of insurability. To add benefits or riders (except where your existing contract allows you to do so without evidence of insurability) or change ratings as part of the conversion, please use our policy change form. Please complete this form and return it to the address below together with an illustration for the new insurance. Foresters 789 Don Mills Road Toronto, ON M3C 1T9 Canada INSURANCE TO BE CONVERTED (Existing) Policy or Certificate Number Owner s SIN Owner (First, Middle, Last) Coverage to be converted Base Coverage Term Rider Spouse Rider Child Rider Other (please specify): Riders to be included on the new policy or certificate when the base is converted Accidental Death Benefit Waiver Note: Waiver of premium coverage on the new contract will expire at age 60, which may be earlier than on your existing contract Other (please specify) Note: You can only use this form to add riders to the new insurance if your existing contract says you can do so without providing evidence of insurability. Please review the conversion section of your contract for more detail. Insured Person under coverage to be converted Name (First, Middle, Last) Date of Birth (mm/dd/yyyy) Current Face Amount $ CONVERSION REQUEST Product to be converted to (New) Attach illustration For New Product Advantage Whole Life (ADV) Please choose: ADV0 ADV1 ADV2 Do you elect the Automatic Premium Loan Provision? Yes No (if Yes, overdue premium may be deducted from the cash value and become a loan against it) Please select a dividend option: Paid-up Additions (only option available for ADV1 or ADV2) Paid in Cash Leave on Deposits Reduce Premiums Passport Universal Life (YRT Cost of Insurance) Death Benefit: Level Insured Amount Investment Instructions: Insured Amount Plus Total Account Value Account Name Investment Allocation % Account Name Investment Allocation % Account Name Investment Allocation% LifeCare Term 75 (for conversions from LifeCare Term 10 only) Face Amount of New Product (i.e. amount to convert) $ 1 105435 CAN (02/13)
Face Amount to Retain under Existing Product (for partial conversions only) Premium for New Product If paying monthly, please complete and attach Monthly PAC Authorization form. Otherwise, attach a cheque for first payment. When we process your conversion request, the face amount of Existing Product will be reduced by the amount of insurance converted. If there is any remaining insurance under Existing Product, do you want to: Continue Existing Product with remaining face amount, or Terminate Existing Product. Note: If the existing product is anything but preferred term and the face amount of the existing product after conversion is less than the minimum for that product type, the existing product will automatically terminate, regardless of the option chosen in this section. However, if the existing product is preferred term and the remaining face amount of the existing product after conversion is greater than or equal to $50,000 and you have chosen to continue the remaining coverage on the existing product then we will honor your request. Annual $ Mode Monthly (pre-authorized payments) Semi-Annual (direct billing) Annual (direct billing) Modal Premium $ PRIMARY BENEFICIARIES (NEW PRODUCT) Name (First, Middle, Last) Date of Birth (mm/dd/yyyy) Address Beneficiary to Insured Person (In Quebec, to Owner) Share % Total must equal 100% 100% SECONDARY BENEFICIARIES (NEW PRODUCT) Name (First, Middle, Last) Date of Birth (mm/dd/yyyy) Address Beneficiary to Insured Person (In Quebec, to Owner) Share % Total must equal 100% 100% Quebec Insurance Only If you have named your spouse or civil union partner as a beneficiary, the designation will be irrevocable unless you select: Revocable Notes: 1) Except as noted above for Quebec, beneficiaries are revocable unless you write the word Irrevocable beside the beneficiary s name. In Nova Scotia, to name an irrevocable beneficiary, you must also complete the Irrevocable Designation Acknowledgement form. 2) If you designate an irrevocable beneficiary, your rights under this insurance will be limited. For example, to name a new beneficiary, you will need the existing irrevocable beneficiary s consent or, where permitted by law, a court order. 3) A secondary beneficiary will not receive any share of the proceeds unless there is no primary beneficiary who is alive and entitled to receive the proceeds when they become payable. 4) For LifeCare policies only: a. You can only name a beneficiary for insurance purchased in Alberta, British Columbia, Manitoba or Quebec. b. For policies purchased in Manitoba only: any beneficiary you designate is revocable. You cannot name an irrevocable beneficiary. c. By completing this section, you are naming a beneficiary to receive any Return of Premium on Death benefits. If you would like to name a beneficiary to receive other benefits under this policy, please complete the Beneficiary Designations for LifeCare and Health Security Plus form number 105567. 2 105435 CAN (02/13)
TRUSTEE (NOT APPLICABLE IN QUEBEC) If you have named a beneficiary who is a minor, please name a trustee to receive any proceeds payable to the child before he or she comes of age. Beneficiary s Name (First, Middle, Last) Trustee s Name (First, Middle, Last) Trustee s Address Trustee to Beneficiary AUTHORIZATION OF CHANGE - to be completed by each owner and any existing irrevocable or preferred beneficiary or collateral assignee under the New Product, and a parent or guardian for each minor child to be insured under the New Product In this section, you and your mean the owners of the Existing Product, the parent or guardian (or tutor, in Quebec) of any insured children under age 16 (under age 18 in Quebec), any irrevocable beneficiary or collateral assignee on the Existing Product. We, us and our mean the insurer that will insure the New Product. For Life Option Enhanced and LifeCare, the insurer is Foresters Life Insurance Company; for Advantage Whole Life and Passport Universal Life, it is The Independent Order of Foresters. By signing below: You acknowledge that we will process your request for conversion in accordance with the terms of your contract and our current administrative rules. You have read this application for conversion, and confirm that the statements in it are true and complete. You consent to the conversion requested as described in this application for conversion. You authorize the original insurer to release all information connected with the Existing Product to us and our reinsurers, and authorize us to use that information to administer the New Product. You agree that we have the right to contest the new insurance based on the evidence of insurability submitted when the original insurer issued or reinstated the Existing Product. o This means that we be entitled to void the new insurance if a material misrepresentation was made with respect to the Existing Product. o The time limits for contestability and suicide will run from the date Existing Product was issued or last reinstated, whichever is later. You agree that if we issue insurance as requested in this application for conversion: o On the effective date of the new coverage, the coverage you are converting and any coverage to be canceled, as described in this application for conversion, will terminate. Depending on the amount of insurance to be converted or canceled, this means that the existing policy or certificate may terminate. You consent to this termination. o You agree that the new insurance satisfies the original insurer s obligation to provide additional insurance under existing Product. The original insurer is released from this obligation as if the original insurer had provided the new insurance. o The current owner(s) of Existing Product will be the initial owner(s) of New Product. You have read and understood the final version of the illustration for New Product, if one is required. If you are a beneficiary or collateral assignee, you consent to the termination of your rights with respect to the insurance to be converted and canceled. You understand that you may not have any rights with respect to the New Product. 3 105435 CAN (02/13)
Signature Instructions and Notes 1) If any owner, collateral assignee or beneficiary is a company, we will require: Two Signing officers signatures and titles OR One signing officer s signature and title and the corporate seal OR One signing officer s signature and title, and his or her initials to confirm that he or she is the only signing officer for the company and there is no corporate seal. 2) The current beneficiary must sign to release his or her rights if he or she is a: Preferred Beneficiary: o A preferred beneficiary is a beneficiary who was named prior to July 1, 1962, in all Provinces except Quebec, who is one of the following to the Insured Person: husband, wife, child, adopted child, grandchild, and child of adopted child, parent or adoptive parent. o However the preferred beneficiary does not have to sign to consent if you are only changing the beneficiary from one preferred beneficiary to another. Irrevocable Beneficiary: o An irrevocable beneficiary is a beneficiary whom you named to receive insurance money if: The owner has specified on the beneficiary designation form that the designation is to be irrevocable, and has complied with any applicable formalities required to make the designation irrevocable under provincial law; or In Quebec only, a beneficiary who is the spouse or, currently, civil union partner of the owner, if the owner did not specify on the beneficiary designation form that the designation was to be revocable. Owners Owner s Signature : Witness Signature (other than Beneficiary): Owner s Signature ( if company owned): Witness Signature (other than Beneficiary-if company owned): If current owner is a company, please have two officers sign, or one officer with corporate seal. If you are the only signing officer and there is no corporate seal, please sign above, and initial here to confirm Irrevocable /Preferred Beneficiaries (if applicable) Beneficiaries Signature: Witness Signature (other than Owner): Beneficiaries Signature (if a company): Witness Signature (other than owner if company owned): If current beneficiary is a company, please have two officers sign, or one officer with corporate seal. If you are the only signing officer and there is no corporate seal, please sign above, and initial here to confirm 4 105435 CAN (02/13)
Collateral Assignee (if applicable) Assignee s Signature : Witness Signature (other than Beneficiary): Assignee s Signature (if company owned): Witness Signature (other than Beneficiary) (if company owned): If current assignee is a company, please have two officers sign, or one officer with corporate seal. If you are the only signing officer and there is no corporate seal, please sign above, and initial here to confirm Agent s Attestation Agent s Name: Agent Code: Agent s Address: By signing below, the agent confirms that, to the best of his or her knowledge, the information in this application for conversion is true and complete, and the agent has reviewed original unexpired photo identification for each person who will own the new insurance as listed below: Owner s name: Photo identification Type Driver s Licence Passport Citizenship Card Other (please specify): Jurisdiction that issued ID: Identification number: Expiry Date: Agent s Signature Date Instructions If there is more than one owner, please attach a duplicate of this page for each owner. Please complete this form and return it to the insurer for the insurance to be converted. 5 105435 CAN (02/13)