You are not eligible for the conversion of your group long-term disability insurance (LTD) if:

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1 Request for Conversion of Long-Term Disability insurance (LTD) Eligibility You are not eligible for the conversion of your group long-term disability insurance (LTD) if: You reached age sixty three (63) on your last birthday; you are currently disabled under the terms of your group policy; immediately prior to your termination of employment or at the time of cancellation of the long-term disability insurance you were not at work, you left your job, or if you were on a leave of absence. you retired, or receive a pension from a public pension plan or a pension plan sponsored by the employer; you become eligible for coverage under another long-term disability plan within 31 days of termination or cancellation of your long-term disability insurance - if you have already applied for conversion coverage and you become eligible for coverage under another plan, you are required to notify Humania Assurance. You are eligible for the conversion only if: your group long-term disability insurance ended as a result of termination, cancellation or withdrawal of such insurance by your employer and; you were covered for long-term disability insurance for at least twenty-four (24) continuous months without disability claim, under a plan sponsored by your employer at the time of termination or cancellation of the insurance; at the time of termination or cancellation of the insurance, you were insured by Humania Assurance for a continuous period of at least 12 months without disability claim; your request for conversion must be received at Humania Assurance within 31 days following your termination of employment or termination of your group LTD coverage. Conversion procedure The request for group LTD conversion must be received at Humania Assurance within 31 days following the date your group LTD insurance ends. Upon approval of your request for conversion, an individual disability policy will be sent directly to the address indicated in Part 2 The Insured The converted policy will be effective at 00:01hours, on the day your group LTD terminates. Premium payment must be by monthly pre-authorized bank withdrawals. Steps to follow : 1. Read the Eligibility section above to determine if you are eligible for the conversion; 2. Calculate the maximum monthly benefi t: (your monthly basic earnings) x (insured % of your group policy) x 50% - This information can be obtained from your employer. 3. Complete Part 2 The Insured and Part 3 Coverage requested 4. Have your employer fi ll out Part 1 The employer 5. Complete, date and sign Tobacco Use questionnaires for Non-Smoker rates. 6. Complete, date and sign part 5 Pre-Authorized Debit Agreement (PDA) 7. Send the completed Request for Conversion of Long-Term Disability to the following address : Humania Assurance Inc. 1555, Girouard Street West, P.O. Box Saint-Hyacinthe, Quebec J2S 7C8 8. Your insurance premium will be determined by your age at your last birthday and your occupational class. If you have any questions, you may contact Customer Service at

2 Part 1 - The employer Name of employer: Address: City: (street no.) (apt.) Province: Postal code: Group LTD plan number: Division: Group LTD Plan maximum monthly benefi t: Was this person covered under the current LTD benefi t for at least twelve (12) continuous months? Yes No Was this person covered for LTD at least twelve (12) continuous months in a combination with a previous group LTD benefit sponsored by you? Yes No Effective date of insurance for this person: Date employee terminated employment: Termination date of the group LTD: Employee s occupation / function / responsibilities at time of termination: Employee s basic monthly earnings at time of termination: $ Reason for employee termination: Date at: (city / province) on: Authorized signature of employer: 2

3 Last name: Part 2 The Insured Frist name: Sexe: Mr. Ms Social insurance number: Date of birth: Home Address: (n o street) (apt.) City: Province: Postal code: Phone number: If the maximum monthly benefi t amount under the group plan from which you are converting is less than 500$, then the insurance will be converted to $500. Signed at: (city / province) on: Signature of applicant: Part 3 Coverage requested Smoker Non-smoker Occupational class: Benefi t period: 2 years 5 years Monthly benefi t: $ Waiting period: 120 days 180 days Regular occupation: 5 years (available only for occupational class 3A and 4A) Are you covered under CSST? Yes No Part 4 Identification of the financial advisor Complete name of service advisor/representative (please print) Code Telephone N o 3

4 Part 5 Pre-Authorized Debit Agreement (PDA) THE PRE-AUTHORIZED DEBIT AGREEMENT (PDA) The Payor named below authorizes Humania Assurance Inc. (Humania Assurance) to make scheduled pre-authorized debits (PDA) on the bank account with the fi nancial institution named below, or any other fi nancial institution that the Payor may later designate, for the purpose of paying the insurance premium in accordance with the premium schedule stipulated in the policy contract, including the initial premium. THE ACCOUNT This Agreement must be signed by all persons whose signature is required to affect withdrawals on the account designated below. You must attach a sample cheque marked "VOID". The sample cheque you send to Humania Assurance will serve for all new debits that you may authorize on the account. If you wish to change the account on which the PDA is drawn, you must forward a sample cheque for the new account to Humania Assurance. THE DEBIT You must be the designated Policyowner or the Payor of the policy contract and you must be the holder of the account on which the PDA is made. You must select a debit date between the 1 st and the 28 th of the month, inclusively. The debits will be made at this date each month for the duration stipulated in the policy contract. You can change the date of the debits provided the premium for the current month is paid or is due at least 10 days after the new date selected. The amount of the debit will vary in accordance with the premium as provided for in the policy contract. If the amount of the debit should vary, Humania Assurance is not required to provide notifi cation. Unless otherwise indicated by you, this Agreement shall be valid for all renewals and conversions of your policy contract. CANCELLING THIS AGREEMENT You can end this Agreement at any time for all policies included in it, by proving 10 days written notice. You may obtain further information on your right to cancel a PDA Agreement by visiting the Canadian Payments Association website at THE CONSEQUENCES OF NON-PAYMENT You are solely responsible for the consequences of a non-payment and any obligations that it may give rise to under the terms and conditions of the policy contract. You are in default of payment when a PDA is not honoured because of non-suffi cient funds, closed account or other similar reasons. If your fi nancial institution does not honour a debit because of non-suffi cient funds, Humania Assurance will debit that amount again with the next monthly debit along with a fee of $25 for each debit not honoured. Humania Assurance may also terminate this Agreement and the annual premium would then be due for all policies covered by this Agreement. A notice of "Stop Payment" initiated by you without prior agreement with Humania Assurance for the payment of the premium, may result in the cancellation of all policies covered by this Agreement. RIGHT TO REIMBURSEMENT You have certain recourse rights if any debit does not comply with this Agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PDA Agreement. To obtain more information on your recourse rights, contact your fi nancial institution or visit 4

5 Part 5 Pre-Authorized Debit Agreement (PDA) (...continued) PERSONAL INFORMATION In establishing your PDA, Humania Assurance will release and exchange with your fi nancial institution only information that is legally required. BANK ACCOUNT INFORMATION These services are for (check one): Personal Business Use Date of withdrawals (1 st to 28 th ): Name of bank or fi nancial institution: Transit Number: Bank Number: Account Number: Address: (apt.) City: Province: Postal Code: The fi nancial institution named above is hereby authorized now or at any subsequent time to honour the requests for PDA or fees made by Humania Assurance on the above account, including a redraw within 30 days for any debit that was not honoured the fi rst time it was presented. The Payor named above authorizes Humania Assurance to debit such amounts on another account, as the Payor may direct from time to time, upon oral or written instructions. Signed at: this: Name of Payor (Account Holder): day of: (month / year) First Name of Payor (Account Holder): Name of Second Payor: (account Holder) (if any) First Name of Second Payor: (account Holder) (if any) Signature of Payor: Signature of Second Payor, if any: ATTACH A SAMPLE VOID CHEQUE HERE (if applicable) SAMPLE "VOID" CHEQUE 5

6 Cancellation right At the policyowner s request, the policy could be cancelled by submitting a written request and returning the policy to the Insurer within 10 days of its receipt. Any premium paid under the policy will be refunded to the Policyowner. Notice concerning files and personal information In order to ensure the confi dentiality of the personal information held concerning you, Humania Assurance Inc., will establish an insurance fi le in which the information concerning your application for insurance and information concerning any insurance claim will be held. Access to this fi le will be restricted to Humania Assurance Inc. employees, reinsurer or mandatories who will be responsible for underwriting, administration, investigation and claims, or any other person designated or authorized by you. Your fi le will be kept in the Company s head offi ce. You are entitled to examine the personal information contained in this fi le, and if required, to have the information corrected by submitting a written request to the address below: Access to Information Officer, Humania Assurance Inc Girouard Street West, P.O. Box 10000, Saint-Hyacinthe, Quebec J2S 7C8 Please be informed that, in the regular process of examining your application, Humania Assurance Inc. may request an investigation report to gather information based on personal interview with your acquaintances. The investigation may cover your reputation lifestyle and fi nances. A representative of the company retained to prepare these reports may also visit or telephone you. Receipt Deposit receipt for: Received the sum of: /100 ($ ) Signed at: on: month / day / year Signature of representative: Code: Telephone: Humania Assurance Inc., 1555 Girouard Street West, P.O. Box 10000, Saint-Hyacinthe, Quebec J2S 7C8 6

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