Request for title changes

Transcription

1 1, Complexe Desjardins 95 St. Clair Avenue West ontreal (Quebec) H5B 1E2 Toronto ON 4V 1N7 Request for title changes Please complete this form in BLOCK LETTERS. Instructions Please provide policy number policyowner s name before section A. Please return all pages of this form. In order to: 1. Change the policyowner or add a second policyowner, fill out sections A J follow the instructions for a designation or change of beneficiary. 2. Designate or change the beneficiary for life insurance, fill out sections B J. 3. Designate or change the beneficiary for long term care insurance, fill out sections C J. 4. Designate or change the beneficiary for critical illness insurance health coverage, fill out sections D J. 5. Designate or change the trustee for minor beneficiary, fill out sections E J. 6. Designate or change the contingent policyowner, fill out sections J. 7. Designate or change the contingent beneficiary, fill out sections G J. 8. Change name for individuals legal entities, fill out sections H J. 9. Change the policyowner following the death of the current policyowner, fill out sections I follow the instructions for change of policyowner. Representative Information inancial center no. (internal use) Representative no. (internal use) 09614A (13-05) Use of the masculine gender should be understood to include both men women.

2 Page 2 Important Information CHANGE O POLICYOWNER(S) or a policyowner change, if no beneficiary is designated, the new policyowner s estate will be appointed as beneficiary. If the new policyowner wishes to keep the same beneficiary, the new policyowner must complete the appropriate beneficiary section to designate the beneficiary again. If the current policyowner or the new policyowner is a legal entity (company, business, corporation, cooperative or trust), one of the following guidelines must be applied: enclose a copy of a resolution from the board authorizing the person signing for the legal entity OR a copy of the latest corporate filing documentation with the provincial authorities. Please also complete form 08295E - Required Additional Information on a Corporation or Oganization. If applicable, the additional benefits related to disability, death or loss of job attached to the former policyowner will be cancelled. or an assignment resulting from a divorce or separation, enclose a copy of the decree. AIR ARKET VALUE The term fair market value (V) is defined as the price we can obtain, given general market conditions, during the sale of a property between prudent, informed, unrestricted parties acting at arm s length. NON-AR S LENGTH TRANSACTION As a general rule, for a contract held by an individual, a transfer is considered a non-arm s length transaction when the new policyowner is an ascendant or a descendent of the current policyowner or when he is related by blood, marriage or adoption. or legal entity held contracts, a transfer is considered a non-arm s length transaction when the current policyowner holds a controlling interest in an entity in which he will become the new owner or vice-versa. or a transfer between persons not dealing at arm s-length, the adjusted cost basis (ACB) for income tax purposes equals the policy cash surrender value on the transfer date, irrespective of the consideration paid for the transfer, if any. or an arm s-length transfer, the ACB is adjusted to the consideration paid. If no consideration has been paid for an arm s-length transfer, the ACB is then adjusted to the cash surrender value (deemed to be the fair market value). If you are unsure about the designation (arm s or non-arm s length) of this transfer, you should contact a tax expert because of the serious tax consequences involved. DESIGNATION OR CHANGE O BENEICIARY(IES) or the province of Quebec: the designation of the legally married spouse (married or civil union spouse) as beneficiary is IRREVOCABLE unless stipulated otherwise. The designation of any other person as beneficiary is REVOCABLE unless stipulated otherwise. or rest of Canada (provinces territories): this beneficiary designation is REVOCABLE unless stipulated otherwise. : means that the beneficiary designation can be changed without the beneficiary s consent. : means that the beneficiary designation cannot be changed without the beneficiary s consent. The irrevocable designation of a minor cannot be changed until he reaches the age of majority. All new primary beneficiary designations terminate all previous primary designations, but do not affect any existing contingent beneficiary designations. In cases where a financial institution is designated as beneficiary, indicate the name of the financial institution that it is beneficiary up to the loan balance amount enter the number date of the loan. The amount over above the balance owing is distributed among the other beneficiaries according to their percentage share. If the beneficiary is deceased, the policyowner s estate will be appointed, unless a contingent beneficiary has been designated. The new beneficiary cannot sign as a witness. The beneficiary cannot consent to a change if he is not of the age of majority. If the irrevocable/preferred beneficiary is deceased, enclose an original death certificate. The designation of estate applies to the policyowner s heirs not those of the insured. The percentage allocated to all of the beneficiaries of each insured must add up to 100. DESIGNATION OR CHANGE O A TRUSTEE OR A INOR BENEICIARY or the province of Quebec, in the section irst last name of beneficiary, indicate the name of the trust, for example trust for Julie Smith. IPORTANT NOTICE: for the province of Quebec, this section is intended to inform Desjardins inancial Security Life Assurance Company of the designation or change of trustee, which has to be done either through a fiduciary will or a fiduciary agreement. Consequently, this section cannot be used in Quebec to designate or change a trustee, but is for information purposes only. DESIGNATION OR CHANGE O CONTINGENT POLICYOWNER The contingent policyowner will become the new policyowner of the policy upon the death of the current policyowner. DESIGNATION OR CHANGE O CONTINGENT BENEICIARY If the primary beneficiary should predecease the insured, the contingent beneficiary replaces the primary beneficiary.

3 Page 3 Policy no. irst last name of policyowner 1 irst last name of policyowner 2 A - Change of Policyowner or Addition of Second Policyowner (or addition of second policyowner, list both policyowners.) A1 - New Policyowner(s) - Individual(s) irst name irst name Last name Last name (YYYY//DD) (YYYY//DD) Relationship to insured (matory) Relationship to insured (matory) Social insurance number (if matory) Social insurance number (if matory) Address Address City City Province Postal code Province Postal code Telephone Res. ( ) Bus. ( ) Ext. Cell. ( ) Telephone Res. ( ) Bus. ( ) Ext. Cell. ( ) A2 - New Policyowner(s) - Legal Entity (Complete orm 08295E - Required Additional Information on a Corporation or Organization.) Legal entity name Relationship to insured Entity. Address City Province Postal code Telephone Bus. Ext. A3 - atory Questions (or income tax purposes, please complete the following for a change of policyowner on a contract that provides life insurance coverage.) 1. a) Is the new policyowner the ex-spouse* of the previous policyowner? If YES, is the transfer due to a legal ruling, decision or a written agreement? If there is no legal ruling, decision or written agreement, what is the value of the consideration fair market value (V)**? (You must indicate an amount even if it is zero.) $ b) Is the new policyowner the spouse*, the child* or grchild* of the previous policyowner? c) Is the new policyowner the father, mother, grfather, grmother, brother or sister of the previous policyowner? 2. inancial year end date (/DD). /DD 3. This section must be completed if the change of policyowner involves a legal entity (ex.: a company). a) Is this a non-arm s length transfer*? (See details in section Important Information.) b) If NO, what is the value of the consideration (V)**? (You must indicate an amount even if it is zero.) 4. Is the transfer of the contract made to a creditor for the purpose of securing a debt or a loan (other that a policy loan)? * As defined by the Income Tax Act. ** or the purposes of tax laws, Desjardins inancial Security Life Assurance Company will use the higher of the following amounts: the cash surrender value or the value of the consideration V on the date of receipt of the change request (whichever shown above). *** If YES, for the purposes of tax laws, Desjardins inancial Security Life Assurance Company will use the cash surrender value as of the date the change request is received. $ ***

4 Page 4 B - Designation or Change of Beneficiary(ies) - Life Insurance irst last name irst last name (YYYY//DD) arried Civil union spouse arried Common-law spouse arried Civil union spouse arried Common-law spouse arried Civil union spouse arried Common-law spouse C - Designation or Change of Beneficiary(ies) - Long Term Care Insurance Type of benefit irst last name irst last name (YYYY//DD arried HEALTH BENEIT arried arried DEATH BENEIT (I APPLICABLE) arried arried arried D - Designation or Change of Beneficiary(ies) - Critical Illness Insurance Health Coverages Type of benefit CRITICAL ILLNESS INSURANCE AOUNT irst last name irst last name (YYYY//DD arried arried arried DEATH BENEIT (I APPLICABLE) arried arried arried arried HEALTH BENEIT arried arried

5 Page 5 E - Designation or Change of a Trustee for a inor Beneficiary irst last name of proposed insured irst last name of trustee of trustee (YYYY//DD) Relationship to insured of trustee irst last name of beneficiary 1 irst last name of beneficiary 2 irst last name of beneficiary 3 - Designation or Change of Contingent Policyowner (Tax impact will be considered at time of event.) irst last name of contingent policyowner Relationship to policyowner (YYYY//DD) Address City Province Postal code Telephone Res. Cell. Bus. Ext. G - Designation or Change of Contingent Beneficiary(ies) irst last name irst last name (YYYY//DD) arried arried arried H - Change of Name for Individuals Legal Entities (Include document, if applicable.) I, the undersigned policyowner, ask that: be replaced by ollowing: a legal adoption (enclosed document) a legal name change (enclosed document) an error made in the application (YYYY//DD) other (specify): I - Change of Policyowner ollowing the Death of the Policyowner I, the undersigned, having reached the age of majority, declare that (all persons concerned must sign this statement): 1) The policyowner of the policy mentioned above,, died on (YYYY//DD) as evidenced by the death certificate submitted to Desjardins inancial Security Life Assurance Company. 2) The policy mentioned above is included in the deceased s estate. 3A) All provinces territories except Quebec - This declaration is made pursuant to: the certificate of appointment of estate trustee / notarial copy of letters probate 3B) Province of Quebec only - This declaration is made pursuant to: the attached will the attached marriage contract the legislative provisions (if no testamentary provisions exist, attach relevant documents) other (specify): Pursuant to the document mentioned above, the said contract is bequeathed to: irst last name (YYYY//DD) irst last name (YYYY//DD) Continue Section I on page 6

6 Page 6 I - Change of Policyowner ollowing the Death of the Policyowner (cont.) Continuation of 3B WAIVER O HEIRS - ANY HEIR WHO WISHES TO WAIVE HIS RIGHTS UNDER THIS POLICY UST COPLETE THE SECTION BELOW. Acknowledging that, henceforth, they will no longer have any interest in the said policy, the undersigned waive all their rights, claims, privileges obligations related to this policy in favour of: Name of new policyowner(s) Signature of heir waiving his rights (Quebec only) Name of heir waiving his rights (BLOCK LETTERS) Signature of heir waiving his rights (Quebec only) Name of heir waiving his rights (BLOCK LETTERS) Signature of witness Name of witness (BLOCK LETTERS) J - Statements Signatures Date (YYYY//DD) OR A POLICYOWNER CHANGE, STATEENTS 1 AND 2 APPLY. OR A BENEICIARY CHANGE, STATEENT 3 APPLIES. 1- DECLARATION O CURRENT POLICYOWNER(S): I, the undersigned, hereby revoke the current revocable beneficiary(ies) waive all my rights, titles obligations under the contract. I also request, if applicable, the cancellation of any waiver of premium benefit on my life assign my contract in favour of the policyowner(s) designated in section A. 2- DECLARATION O NEW POLICYOWNER(S): I, the undersigned, hereby consent to becoming policyowner of this contract with all the associated rights, titles, privileges obligations. 3- DECLARATION O REVOKED BENEICIARY(IES): I, the undersigned, hereby consent to the revocation of my designation as irrevocable/preferred beneficiary of the insurance. Signature of current policyowner 1 (individual) Signature of new policyowner 1 (individual) Signature of current policyowner 2 (individual) Signature of new policyowner 2 (individual) Signature of the person authorized to sign for the current policyowner (legal entity) Signature of the person authorized to sign for the new policyowner (legal entity) Signature of irrevocable/preferred beneficiary Name title (BLOCK LETTERS) of the person authorized to sign for the current policyowner (legal entity) Name title (BLOCK LETTERS) of the person authorized to sign for the new policyowner (legal entity) Name of irrevocable/preferred beneficiary (BLOCK LETTERS) Signature of consent of assignee Name of consent of assignee (BLOCK LETTERS) Signature of executor (if applicable) Name of executor (if applicable) (BLOCK LETTERS) Signature of witness Name of witness (BLOCK LETTERS) K - Registration by Desjardins inancial Security Life Assurance Company Date (YYYY//DD) Desjardins inancial Security Life Assurance Company has registered this change, but assumes no responsability for the validity or legality of the document. Registered by Date (YYYY//DD)