Insurance Application

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1 Insurance Application Detach this page and deliver to the Proposed Insured(s) and Owner(s). LP257 7/14

2 Detach this page and deliver to the Proposed Insured(s) and Owner(s). INSURANCE APPLICATION Thank you for applying for insurance with Transamerica Life Canada ( Transamerica, we, us ). Before submitting this application to Transamerica, ensure that you have carefully read each of the notices on this page and all other pages of this application. On receipt of this application, we will assess the eligibility of each Proposed Insured for the insurance reuested. We assess each Proposed Insured primarily on the basis of the information that is provided in this application and any other declaration made in connection to this application. Factors that we consider when underwriting an application for insurance include, but are not limited to, information concerning each Proposed Insured s medical history, physical condition, occupation or avocation, lifestyle and financial situation. Once we have determined the degree of risk that each Proposed Insured represents, we will determine if the insurance applied for can be issued. Should you ever have any uestions about your policy, please do not hesitate to contact your Independent Insurance Advisor or write to us at Life Client Service Department, Transamerica Life Canada, Yonge Street, Toronto, Ontario, M2N 7J8. NOTICE OF RESCISSION RIGHTS Any policy issued in conjunction with this application may be cancelled by the Owner within ten (10) days of delivery (i) by return of the policy either to us or to the Advisor through whom it was purchased, or (ii) upon receipt by Transamerica of a written reuest for policy cancellation. Upon reuest for cancellation, this policy will be consid ered void as of the Issue Date and all premiums will be refunded. NOTICE REGARDING MIB, INC. Information regarding your insurability will be treated as confidential. Transamerica or its reinsurers may, however, make a brief report thereon to MIB, Inc., formerly known as Medical Information Bureau, a not-for-profit membership organization of insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB, Inc., upon reuest, will supply such company with the information about you in its file. MIB, Inc. receives personal information, and the collection, use and disclosure of such information is governed by the Personal Information Protection and Electronic Documents Act (PIPEDA) and provincial laws. Therefore, MIB, Inc. has agreed to protect such information in a manner that is substantially similar to Transamerica Life Canada privacy and security practices, and in accordance with applicable laws. As a U.S.-based company MIB, Inc. is bound by and such personal information may be disclosed in accordance with applicable U.S. laws. If you have any uestions about MIB, Inc. s commitment to protect the confidentiality and security of your personal information, you may contact the MIB, Inc. Privacy Department at Upon receipt of a reuest from you, MIB, Inc. will arrange disclosure of any information in your file. If you uestion the accuracy of the information in MIB, Inc. s file, you may contact MIB, Inc. and seek a correction. The address of MIB, Inc. s information office is 330 University Avenue, Suite 501, Toronto, Ontario, M5G 1R7, tel. no Transamerica, or its reinsurers, may also release information from its file to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. Information for consumers about MIB, Inc. may be obtained on its website at NOTICE REGARDING INVESTIGATIVE CONSUMER REPORTS AND COLLECTION In connection with this application, an investigative consumer report or credit report may be obtained from an investigative or consumer reporting agency and/or credit bureau. They will collect information for this report on behalf of Transamerica through personal interviews with your neighbours, colleagues, friends or others with whom you are acuainted. Personal information collected may include information about your character, general reputation, personal characteristics, finances, credit and lifestyle. A representative who is employed to make such reports may contact you in person or by telephone in connection with this investigation. Information collected in the investigative report obtained by us is used for the purpose of evaluating risks for life and health insurance in connection with this application. For more details about this report, you may write to us at the Life Client Service address noted above. NOTICE REGARDING COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION Transamerica collects, uses and discloses your personal information as described in the Notices regarding MIB, Inc., Investigative Consumer Reports and the Personal Information Authorization sections of this application. In addition, we collect personal information about you from this application and any supplementary forms and uestionnaires, as described in the above Notices, and from the following sources: Physicians and other medical and health care practitioners and providers; hospitals, clinics and other medical facilities; MIB, Inc. and other insurers and reinsurers; investigation, consumer and credit reporting agencies; motor vehicle and driver record authorities in any relevant jurisdictions; your Independent Insurance Advisors, including the Independent Advisor s Report section of your application; Transamerica s affiliates. The information collected from the above sources is used for the following purposes: Evaluating, assessing and investigating this application, our insurance risks and any claims you submit; evaluating your insurance and financial needs; administering and servicing the insurance and/or financial products we provide; and reporting information to the Canada Revenue Agency in accordance with federal legislation. If you provide your Social Insurance Number (SIN), it will be used for the following purposes only: tax reporting, record keeping and identification, when needed. The use of your SIN for identification purposes is optional. You may withdraw consent for use of your SIN for identification purposes at any time by contacting Transamerica s Client Services using the contact number listed on your policy. Further note: certain transactions reuested under the universal life policy may reuire you to provide the SIN before processing. You have the option to provide your SIN now to avoid any future delays. Your personal information may be shared with the entities and persons identified above for the purposes of obtaining the information reuired, and it may otherwise be shared with or disclosed to managing general agencies, distributors and market intermediaries and their employees and agents and your Independent Advisors for purposes identified above. Your banking information may be disclosed to the financial institution(s) processing your pre-authorized debit payments. If necessary, your personal information may also be shared with your beneficiaries in relation to a claim. Your personal information may be securely used, stored or accessed in other countries and may be subject to the laws of those countries. For example, personal information may be disclosed in response to demands or reuests from government authorities, courts or law enforcement in these countries. From time to time we may use your personal information to determine which other insurance and financial products and services may meet your needs and to offer them to you. We may disclose your personal information to our affiliated companies for their own use for such purposes. However, we will not disclose your health information to our affiliates for such purposes. By signing and submitting this application on your own behalf and/or on behalf of any minor, you give your consent to the collection, use and disclosure of your and/or the minor s personal information as described above and elsewhere in this application. Upon receiving your application, Transamerica will establish and maintain a file containing your personal information, which will be accessible at our Head Office. Your file will be accessible to only those employees and authorized representatives of Transamerica responsible for administering your file, and other persons authorized by you or by law. Subject to exceptions set out in applicable legislation, you may access your file and reuest corrections to your personal information by sending a written reuest to: Privacy Officer, Transamerica Life Canada, Yonge Street, Toronto, Ontario, M2N 7J8. Your personal information will be collected, used, disclosed, shared and treated as described herein, or as otherwise described at or before the time of collection, use or disclosure, or as otherwise permitted by law. To review our privacy policy, visit DISCLOSURE OF COMPENSATION The insurance product you are being offered is supplied by Transamerica, a company licensed to conduct business in all provinces and territories of Canada. The Independent Insurance Advisor/Distributor soliciting this insurance application is a licensed insurance Advisor representing Transamerica and will receive compensation from us upon the completion of this transaction. You are not obligated to transact any other business with Transamerica, the Advisor/Distributor or any other person or entity as a condition of this application. i

3 Application No. Policy No. What type of policy are you applying for: Individual Life Joint First-to-Die Joint Last-to-Die Multiple Life Coverages Names of all Proposed Insureds to be covered under this policy: This is a: New Policy Replacement of Transamerica Policy # Insured Exchange Option Addition of coverage to Transamerica Policy # MAIN PURPOSE OF INSURANCE: Buy and Sell Critical Illness Protection Estate Planning Key Person Insurance Life Protection Partnership Retirement Planning Other 1. INSURED 1 Please print in block letters Mr. Mrs. Ms. Miss First Name Middle Initial Last Name Other: Identification Document* Identification Document Number* Issuing Jurisdiction* *Please refer to an original, non-expired passport, birth certificate, driver s license, Canadian citizenship, age of majority or Canadian Armed Forces identification (preferably photo I.D.). 2. Date of Birth: Age for premium: Gender: M F Smoking Class: Smoker Non-smoker DD / MM / YYYY Country of birth: SIN: (Optional: complete only if you are the Owner and applying for a Universal Life policy) Former/Maiden Name: 3. Current address (Number and street name) Apt/Suite City Province Postal Code Home telephone: ( ) Business telephone: ( ) 4. I understand the language in which this application is written. Yes No If No, have the details of this application been fully explained to you in your preferred language and are they completely understood? Yes No 5. a) What is the Proposed Insured s residency status? Canadian Citizen Landed Immigrant/Permanent Resident Number of years/months residing in Canada: Years Months Contract Worker (provide copy of work permit) Number of years/months residing in Canada: Years Months Other (give details of current status) Number of years/months residing in Canada: Years Months b) Are you a Resident for Canadian income tax purposes? Yes No c) Complete only if the Proposed Insured is the Owner and applying for a Universal Life policy: Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN). Yes No United States Taxpayer Identification Number (TIN):. 6. Is the Proposed Insured currently employed? Yes No If No, provide details Is the Proposed Insured a student? Yes No If Yes, Full Time Part Time Occupation: Name of employer: # of years: Employer s address: Duties: Annual Income $ Total Net Worth $ 1 *FRM-LP2578/12* LP257 7/14

4 7. INSURED 2 Please print in block letters Mr. Mrs. Ms. Miss First Name Middle Initial Last Name Other: Identification Document* Identification Document Number* Issuing Jurisdiction* *Please refer to an original, non-expired passport, birth certificate, driver s license, Canadian citizenship, age of majority or Canadian Armed Forces identification (preferably photo I.D.). 8. Date of Birth: Age for premium: Gender: M F Smoking Class: Smoker Non-smoker DD / MM / YYYY Country of birth: SIN: (Optional: complete only if you are the Owner and applying for a Universal Life policy) Former/Maiden Name: 9. Current address (Number and street name) Apt/Suite City Province Postal Code Home telephone: ( ) Business telephone: ( ) 10. I understand the language in which this application is written. Yes No If No, have the details of this application been fully explained to you in your preferred language and are they completely understood? Yes No 11. a) What is the Proposed Insured s residency status? Canadian Citizen Landed Immigrant/Permanent Resident Number of years/months residing in Canada: Years Months Contract Worker (provide copy of work permit) Number of years/months residing in Canada: Years Months Other (give details of current status) Number of years/months residing in Canada: Years Months b) Are you a Resident for Canadian income tax purposes? Yes No c) Complete only if the Proposed Insured is the Owner and applying for a Universal Life policy: Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN). Yes No United States Taxpayer Identification Number (TIN):. 12. Is the Proposed Insured currently employed? Yes No If No, provide details Is the Proposed Insured a student? Yes No If Yes, Full Time Part Time Occupation: Name of employer: # of years: Employer s address: Duties: Annual Income $ Total Net Worth $ 2

5 Application No. 13. OWNER The advisor must verify identity of all Owners Policy ownership applies to all coverages. The Owner must be at least 16 years of age (at least 18 years of age in the Province of Québec). a) What language do you reuest related documents be in? English Français b) The Owner will be (all of) the adult Proposed Insured(s) unless indicated otherwise below: Proposed Insured 1 Proposed Insured 2 Owner(s) as identified below For a Universal Life policy, if the Owner is a Corporation, Non-Corporate Entity or Trust, complete Pages 11 and 12 OWNER 1 Legal Name (first, middle initial, last and/or Legal company/entity name) Relationship to Proposed Insured Identification Document* Identification Document Number* Issuing Jurisdiction* Principal Business or Occupation Date of Birth (DD/MM/YYYY) SIN (Optional: complete only if you are applying for a Universal Life policy) Current Address (Number and street name) Apt/Suite City Province Postal code Phone Number ( ) Complete only if you are applying for a Universal Life policy: Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN). Yes No United States Taxpayer Identification Number (TIN): OWNER 2 Legal Name (first, middle initial, last and/or Legal company/entity name) Relationship to Proposed Insured Identification Document* Identification Document Number* Issuing Jurisdiction* Principal Business or Occupation Date of Birth (DD/MM/YYYY) SIN (Optional: Complete only if you are applying for a Universal Life policy) Current Address (Number and street name) Apt/Suite City Province Postal code Phone Number ( ) Complete only if you are applying for a Universal Life policy: Are you a U.S. resident for tax purposes (which includes a U.S. citizen)? If Yes, provide a U.S. Taxpayer Identification Number (TIN). Yes No United States Taxpayer Identification Number (TIN): *Please refer to an original, non-expired passport, birth certificate, driver s license, Canadian citizenship, age of majority or Canadian Armed Forces identification (preferably photo I.D.). c) Multiple Owners i) Canadian Provinces (excluding Québec) Where there are multiple Owners, the policy will be issued to all Owners with Right of Survivorship should an Owner die while the policy is in effect, the deceased Owner s interest automatically transfers to the surviving Owner(s) unless the option Tenants in Common is selected below. Tenants in Common (undivided co-ownership) should an Owner die while the policy is in effect, the deceased Owner s interest will transfer to his/her estate unless a contingent Owner has been named for such Owner. ii) Province of Québec only Ownership must be Tenants in Common. Tenants in Common (undivided co-ownership) means that should an Owner die while the policy is in effect, the deceased Owner s interest will transfer to his/her estate. Please name one another as contingent owners if Right of Survivorship is desired. Please provide relationship of each Owner to all other Owners: d) Mailing Address (Where there are multiple Owners, all notices and statements will be mailed to Owner 1 unless another address is indicated) Other (please insert address below) Number and street name City Province Postal code 3

6 e) Contingent Owner For Life and Critical Illness Insurance Policies, if you wish to have your ownership interest transferred to another person in the event of your death, complete this section. If Joint Ownership is Right of Survivorship, the ownership interest will only be transferred to the contingent owner listed for the last surviving Owner upon that Owner s death. If Joint Ownership is Tenants in Common and no contingent owner is named, the deceased Owners interest will transfer to his/her estate. For Critical Illness Policy a contingent owner can be designated in Alberta, British Columbia, Manitoba, Ontario and Québec. If no contingent owner is named, upon death of the policy owner, ownership will be transferred to the policy owner s estate. Name of Owner Name of Contingent Owner Relationship to Owner Current address of Contingent Owner Name of Owner Name of Contingent Owner Relationship to Owner Current address of Contingent Owner OWNER 1 OWNER 2 f) Politically Exposed Foreign Person YES NO YES NO i) Is a premium and/or lump sum payment eual to or greater than $100,000 being made or to be made? If the answer is Yes, each Proposed Owner must complete uestion f) ii). ii) Do you, the Proposed Owner(s), or any person to whom you are related by blood or marriage (including your common-law partner), hold, or have held in the past, any of the following positions in a country other than Canada: head of state, member of the executive council of government or member of the legislature, deputy minister (or euivalent), ambassador or ambassador s attaché or counsellor, military general (or higher rank), president of state-owned company or bank, judge or leader or president of a political party in a legislature? Each Owner who answers Yes to f) ii) must complete the Politically Exposed Foreign Person Form (IP-LP1165) and submit it along with the application. g) Consent to Receive s to be Completed by the Owner(s) Canada s Anti-Spam Legislation regulates the distribution of commercial electronic messages (e.g. s) to consumers. To comply with this law, Transamerica Life Canada is reuired to obtain your consent for the purposes of sending you commercial electronic messages regarding your policy, product information and marketing material. By providing your address below, you are consenting to receiving commercial electronic messages as outlined above from Transamerica Life Canada. Owner 1 Address: Owner 2 Address: You may withdraw your consent at any time by contacting us at Transamerica Life Canada as follows: Yonge Street Toronto, ON M2N 7J8 Telephone: Fax: at or

7 Application No. 14. BENEFICIARY INSURED 1 For contracts signed in Québec, the designation of spouse (married or civil union) of the Owner as beneficiary is irrevocable unless otherwise specified. All other beneficiary designations in Québec, and all beneficiary designations for contracts signed elsewhere in Canada, are revocable unless otherwise specified. By naming a beneficiary irrevocably, you are giving up substantial control over your policy. Once an irrevocable beneficiary has been designated, his/her consent will be reuired for future dealings with the policy (some exceptions apply in Québec). If naming a minor as irrevocable beneficiary, you should be aware that a minor cannot give consent. All beneficiaries are deemed primary unless otherwise specified. If more than one primary beneficiary is named, then the proceeds are to be eually shared unless otherwise specified; the same applies to contingent beneficiaries. Any breakdown of proceeds MUST be stated in percentages rather than dollar amounts. The total percentage of shares for each of the primary and contingent beneficiaries must eual 100%. A contingent beneficiary is always revocable. Where a minor is designated as a beneficiary, it is recommended that a Trustee be appointed to avoid a payment into court (not applicable in Québec). If all beneficiaries predecease the Proposed Insured, the proceeds are payable to the contingent beneficiaries, if any, otherwise to the Owner or the Owner s estate. If no beneficiary is designated, then the proceeds are payable to the Owner, if living, or the Owner s estate, if deceased. Life Insurance Policy Beneficiary 1. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 2. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 3. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 4. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Check one: Revocable Irrevocable 5

8 BENEFICIARY INSURED 1 continued Critical Illness Rider on a Life Insurance Policy (Do not complete this section if applying for Critical Illness only.) Beneficiary Critical Illness Benefit and/or Early Detection Benefit (If not completed, the beneficiary will be the Life Insured. If the Life Insured is a minor, the beneficiary is the Owner, if living, or the Owner s estate, if deceased.) 1. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 2. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Critical Illness Benefit Return of Premium on Death (If not completed, the proceeds are payable to the Owner, if living, or the Owner s estate, if deceased.) First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Critical Illness Policy Beneficiary Critical Illness Benefit and/or Early Detection Benefit (Beneficiaries may only be designated in Alberta, British Columbia and Québec. If not completed, the beneficiary will be the Insured. In all other provinces, the beneficiary will be the Insured. If the Insured is a minor, the beneficiary is the Owner, if living, or the Owner s estate, if deceased.) 1. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 2. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Check one: Revocable Irrevocable Critical Illness Benefit Return of Premium on Death (Beneficiaries may only be designated in Alberta, British Columbia and Québec. If not completed, the beneficiary will be the owner, if living, or the owner s estate, if deceased. In all other provinces, the beneficiary will be the Owner, if living, or the Owner s estate, if deceased.) First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): 6

9 Application No. 15. BENEFICIARY INSURED 2 For contracts signed in Québec, the designation of spouse (married or civil union) of the Owner as beneficiary is irrevocable unless otherwise specified. All other beneficiary designations in Québec, and all beneficiary designations for contracts signed elsewhere in Canada, are revocable unless otherwise specified. By naming a beneficiary irrevocably, you are giving up substantial control over your policy. Once an irrevocable beneficiary has been designated, his/her consent will be reuired for future dealings with the policy (some exceptions apply in Québec). If naming a minor as irrevocable beneficiary, you should be aware that a minor cannot give consent. All beneficiaries are deemed primary unless otherwise specified. If more than one primary beneficiary is named, then the proceeds are to be eually shared unless otherwise specified; the same applies to contingent beneficiaries. Any breakdown of proceeds MUST be stated in percentages rather than dollar amounts. The total percentage of shares for each of the primary and contingent beneficiaries must eual 100%. A contingent beneficiary is always revocable. Where a minor is designated as a beneficiary, it is recommended that a Trustee be appointed to avoid a payment into court (not applicable in Québec). If all beneficiaries predecease the Proposed Insured, the proceeds are payable to the contingent beneficiaries, if any, otherwise to the Owner or the Owner s estate. If no beneficiary is designated, then the proceeds are payable to the Owner, if living, or the Owner s estate, if deceased. Life Insurance Policy Beneficiary 1. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 2. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 3. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 4. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Check one: Revocable Irrevocable 7

10 BENEFICIARY INSURED 2 continued Critical Illness Rider on a Life Insurance Policy (Do not complete this section if applying for Critical Illness only.) Beneficiary Critical Illness Benefit and/or Early Detection Benefit (If not completed, the beneficiary will be the Life Insured. If the Life Insured is a minor, the beneficiary is the Owner, if living, or the Owner s estate, if deceased.) 1. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 2. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Critical Illness Benefit Return of Premium on Death (If not completed, the proceeds are payable to the Owner, if living, or the Owner s estate, if deceased.) First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Critical Illness Policy Beneficiary Critical Illness Benefit and/or Early Detection Benefit (Beneficiaries may only be designated in Alberta, British Columbia and Québec. If not completed, the beneficiary will be the Insured. In all other provinces, the beneficiary will be the Insured. If the Insured is a minor, the beneficiary is the Owner, if living, or the Owner s estate, if deceased.) 1. First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % 2. First Name, Last Name Check one: Revocable Irrevocable Relationship to Proposed Insured (Proposed Owner in Québec) Primary Contingent Share % If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): Check one: Revocable Irrevocable Critical Illness Benefit Return of Premium on Death (Beneficiaries may only be designated in Alberta, British Columbia and Québec. If not completed, the beneficiary will be the owner, if living, or the owner s estate, if deceased. In all other provinces, the beneficiary will be the Owner, if living, or the Owner s estate, if deceased.) First Name, Last Name Relationship to Proposed Insured (Proposed Owner in Québec) If a minor is designated, indicate Trustee name and relationship to Proposed Insured (not applicable in Québec): 8

11 Application No. 16. INSURANCE HISTORY INSURED 1 INSURED 2 YES NO YES NO a) Has any Application, reinstatement, modification for Life, Critical Illness, Long Term Care or Disability Insurance ever been rated, declined, postponed, cancelled, rescinded or modified in any way? b) i) Is this Insurance intended to replace, or will it cause a change, in any existing Life or Critical Illness Insurance with this or any other Company? ii) If the intent of this application for insurance is to replace an existing Transamerica policy/coverage, does the Owner instruct Transamerica to cancel that policy/coverage on the effective date of the policy being applied for? If Yes for Life, attach the completed Replacement/Comparison Disclosure Forms, LIRD (where applicable). Note: Only the policy owner has the right to cancel the existing policy/coverage. If there is a change in ownership, you must submit a Transfer of Ownership or Letter of Direction signed by the original owner. It s the policyowner s responsibility to continue to pay premiums on the original policy while the new application is being assessed to avoid a lapse in coverage. c) Do you have any of the following insurance in force or pending: Life Insurance, Critical Illness, Disability, Long Term Care? If Yes, complete the table in Question If Yes to uestions a), b) or c), provide additional information in the Remarks section. 17. INSURANCE IN FORCE INSURED 1 INSURED 2 Company Amount of Insurance Type of Insurance Plan: Personal/ Business: Issue Will coverage be: Year Life CI DI LTC P B Changed Replaced $ $ $ $ $ $ If changing, provide details. If replacing a TLC policy, provide policy # In Force Pending Remarks Details of any Yes answers. If applicable, attach the appropriate completed uestionnaire(s). QUESTION # INSURED # DETAILS 9

12 FINANCIAL INFORMATION Personal where the face amount is $1,000,000 or more, complete Question 18. Business where the Insurance is for business purposes, the Owner or beneficiary is a corporation, non-corporate entity or trust, complete Question PERSONAL a) Financial Details INSURED 1 INSURED 2 Earned Income (Last Year) $ $ $ Unearned Income (Last Year) Bonus, Dividends, Interest, etc. $ $ $ Assets: Cash, Real Estate, Stocks, Bonds, etc. $ $ $ Liabilities: Mortgages, Loans, etc. $ $ $ Total Net Worth $ $ $ Owner (where individual Owner is not a Proposed Insured) 19. BUSINESS a) Name of Business: b) Nature of the Business: c) Financial Details: Assets $ Percentage of Ownership Held by the Proposed Insured Liabilities $ INSURED 1 % Net Worth $ INSURED 2 % Fair Market Value of the Business: d) Insurance of Other Partners of the Business Name, Title/Occupation Life Insurance Critical Illness Insurance % of Business In Force Pending In Force Pending Ownership $ $ $ $ $ $ $ $ $ $ $ $ Financial Statement enclosed to follow Letter of Explanation enclosed to follow Additional Comments: 10

13 Application No. CORPORATE/NON-CORPORATE ENTITY/TRUST IDENTIFICATION (COMPLETE ONLY FOR UNIVERSAL LIFE POLICIES) This section along with the International Tax Classification for an Entity Form (IP-LP1601) must be completed if the Owner is a Corporation, Non Corporate Entity or a Trust. 1. Please provide the following information on the individual(s) submitting an application on behalf of a Corporation, Non-Corporate Entity or Trust. Identification Identification Name of Individual Job Title Document* Document Number* Issuing Jurisdiction* * Please refer to an original non-expired passport, birth certificate, driver s license, Canadian citizenship, age of majority or Canadian Armed Forces identification (preferably photo ID). 2. Corporation Please provide Corporate information including corporate structure document. For more information on supporting documents reuired refer to the Summary Table. Official Corporate Name Address Place of Federal or Provincial Incorporation Corporation Registration Number Names of all Directors of Corporation (If necessary, attach listing of all directors) Occupation Names of all individuals who directly or indirectly own or control 25% or more of the shares of the Corporation. Name of Individual Occupation Address 11

14 3. Non-Corporate Entity Please provide Non-Corporate Entity information. For more information on supporting documents reuired refer to the Summary Table. Official Name of Entity and Address Place of Issue Registration Number Type of Document/Entity Names of all individuals who directly or indirectly own or control 25% or more of the Non-Corporate Entity. Name of Individual Occupation Address 4. Trust Please provide Trust information. For more information on supporting documents reuired refer to the Summary Table on the next page. Name of person who created the Trust (Settlor) Address Name of Trustee Name of Beneficiary Address Address 12

15 Application No. SUMMARY TABLE Type of account Corporation (Complete section 1 and 2) Non-Corporate Entity (Complete section 1 and 3) Trust (Complete section 1 and 4) What information must be submitted Name and address of the corporation Names of all directors of the corporation Names and addresses of all individuals who directly or indirectly own or control 25% or more of the shares of the corporation. (If this information cannot be obtained, we must keep a record explaining why beneficial ownership could not be determined). Certificate of Incumbency International Tax Classification for an Entity Form (IP-LP1601) Name and address of the entity Name and address of all individuals who directly or indirectly own or control 25% or more of the entity. (If this information cannot be obtained, we need to keep a record explaining why beneficial ownership could not be determined). Certificate of Incumbency International Tax Classification for an Entity Form (IP-LP1601) And include one of the following: Partnership Agreement Articles of association Other similar record that confirms the entity s existence Name and address of all trustees Name and address of all known beneficiaries Name and address of all known settlors of the trust Certificate of Incumbency International Tax Classification for an Entity Form (IP-LP1601) And include one of the following: Trust Agreement Trust Deed Declaration of Trust Other similar record that confirms the entity s existence 13

16 20. INSURANCE APPLIED FOR INSURED 1 UNIVERSAL LIFE INSURANCE Face Amount: Submit an illustration and the Supplement to the Insurance Application for life insurance. DO NOT COMPLETE THIS PAGE IF APPLYING FOR UNIVERSAL LIFE. TERM LIFE INSURANCE Face Amount: 10 Year 20 Year 30 Year with SelectOptions Term Riders Face Amount Benefit Riders Face Amount 10 Year Rider Children s Insurance 20 Year Rider Accidental Death & Dismemberment 30 Year Rider (available only on Term 30 Policy) Waiver of Premium Payor Waiver of Premium* Critical Illness Protection Rider* Benefit *Name of parent or legal guardian. In addition complete, Questions 24 to 41: Benefit Term 10 CI 4 conditions Term 10 CI 25 conditions Term 20 CI 4 conditions Term 20 CI 25 conditions Term to age 65 CI 4 conditions Term to age 65 CI 25 conditions *The Critical Illness Benefit applied for cannot exceed the total life insurance face amount applied for. When applying for a Critical Illness Protection policy, complete this section. CRITICAL ILLNESS PROTECTION Benefit: Term 10 CI 4 conditions Term 20 CI 4 conditions Term to age 65 CI 4 conditions Term 10 CI 25 conditions Term 20 CI 25 conditions Riders Waiver of Premium Payor Waiver of Premium* *Name of parent or legal guardian. In addition complete, Questions 24 to 41: Term to age 65 CI 25 conditions Additional Coverage Benefit Benefit Term 10 CI 4 conditions Term 10 CI 25 conditions Term 20 CI 4 conditions Term 20 CI 25 conditions Term to age 65 CI 4 conditions Term to age 65 CI 25 conditions NOTE: Early Detection Benefit and Childhood Critical Illness Covered Conditions are only available with the 25 conditions Critical Illness Protection products. 14

17 Application No. 21. INSURANCE APPLIED FOR INSURED 2 UNIVERSAL LIFE INSURANCE Face Amount: Submit an illustration and the Supplement to the Insurance Application for life insurance. DO NOT COMPLETE THIS PAGE IF APPLYING FOR UNIVERSAL LIFE. TERM LIFE INSURANCE Face Amount: 10 Year 20 Year 30 Year with SelectOptions Term Riders Face Amount Benefit Riders Face Amount 10 Year Rider Children s Insurance 20 Year Rider Accidental Death & Dismemberment 30 Year Rider (available only on Term 30 Policy) Waiver of Premium Payor Waiver of Premium* Critical Illness Protection Rider* Benefit *Name of parent or legal guardian. In addition complete, Questions 24 to 41: Benefit Term 10 CI 4 conditions Term 10 CI 25 conditions Term 20 CI 4 conditions Term 20 CI 25 conditions Term to age 65 CI 4 conditions Term to age 65 CI 25 conditions *The Critical Illness Benefit applied for cannot exceed the total life insurance face amount applied for. When applying for a Critical Illness Protection policy, complete this section. CRITICAL ILLNESS PROTECTION Benefit: Term 10 CI 4 conditions Term 20 CI 4 conditions Term to age 65 CI 4 conditions Term 10 CI 25 conditions Term 20 CI 25 conditions Riders Waiver of Premium Payor Waiver of Premium* *Name of parent or legal guardian. In addition complete, Questions 24 to 41: Term to age 65 CI 25 conditions Additional Coverage Benefit Benefit Term 10 CI 4 conditions Term 10 CI 25 conditions Term 20 CI 4 conditions Term 20 CI 25 conditions Term to age 65 CI 4 conditions Term to age 65 CI 25 conditions NOTE: Early Detection Benefit and Childhood Critical Illness Covered Conditions are only available with the 25 conditions Critical Illness Protection products. 15

18 22. OTHER PLAN DETAILS a) Special Policy Dates: Date to save age INSURED 1 INSURED 2 Specific Policy/Future Date: INSURED 1 DD / MM / YYYY b) Alternate/Optional Policy: Plan: c) Additional Policy: Plan: Face Amount/Benefit: Face Amount/Benefit: INSURED 2 d) Alternate/Optional Policy: Plan: e) Additional Policy: Plan: Face Amount/Benefit: Face Amount/Benefit: 23. PAYMENT DETAILS Premium Quoted $ For UL, Planned Periodic Premium/Deposit $ a) Initial Premium/Deposit of $ to be paid by: Check only one option below Personal cheue attached Payment upon delivery (temporary insurance is not available with this option) Withdraw from bank account immediately upon receipt of application. (attach cheue, pre-printed with the Payor s name and marked VOID, or a bank Letter of Direction.) b) Future Premiums/Deposits to be paid by: Pre-Authorized Debit: (complete authorization on Page 35) Monthly Quarterly Preferred Date of Withdrawal (days 1 28 only) For Universal Life policies; if you select a withdrawal date that is after your Policy Date, we will automatically set the withdrawal date to match the Policy Date. Direct Bill: Annual Semi-Annual Quarterly c) Provide source of Premium/Deposit (where is the premium/deposit coming from?):. IF THE PAYOR IS SOMEONE OTHER THAN THE INSURED, OWNER OR BENEFICIARY, PLEASE COMPLETE THE IDENTITY AND THIRD PARTY DETERMINATION FORM (IP-LP782) ALL CHEQUES MUST BE PRE-PRINTED WITH THE ACCOUNT HOLDER S NAME AND MADE PAYABLE TO TRANSAMERICA LIFE CANADA 16

19 ADULT PERSONAL HISTORY Application No. INSTRUCTIONS If the Proposed Insured is 16 years of age or greater, complete the Adult Section Questions If the Proposed Insured is less than 16 years of age, complete the Juvenile Section Questions If a Child Rider Benefit is reuested, complete the Child Insurance Rider Section Questions PERSONAL HISTORY (To be completed if the Proposed Insured is 16 years of age or greater.) 24. Have you smoked or used any of the products listed in the table below: INSURED 1 INSURED 2 YES NO YES NO a) in the last 12 months? b) in the last 24 months? If Yes to a) or b), complete the table below. INSURED 1: INSURED 2: Products Quantity Freuency Cigarettes Cigarillos (little cigars) Electronic cigarette Pipe Shisha/hookah (water pipe) Cigars Chewing tobacco Betal nuts Snuff Nicotine patch Nicorette chewing gum Marijuana/Hashish (Joints) Any other smoking cessation products, or used tobacco in any other form Cigarettes Cigarillos (little cigars) Electronic cigarette Pipe Shisha/hookah (water pipe) Cigars Chewing tobacco Betal nuts Snuff Nicotine patch Nicorette chewing gum Marijuana/Hashish (Joints) Any other smoking cessation products, or used tobacco in any other form Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Day Week Month Year Single Use Date of Last Use (MM / YYYY) 17

20 ADULT PERSONAL HISTORY PERSONAL HISTORY continued 25. Within the next 12 months do you expect to travel outside Canada and the United States? If Yes, provide details: countries, cities, purpose of travel, length of stay and expected number of trips per year. If you reuire more space, please use the Remarks section or complete the Foreign Travel Questionnaire (UW-FTQ399). INSURED 1: City and Country Purpose of Travel Length of Stay INSURED 1 INSURED 2 YES NO YES NO # of times per Year INSURED 2: INSURED 1 INSURED LIFESTYLE AND AVOCATION YES NO YES NO a) In the last 12 months, have you piloted an aircraft other than with a commercial/major airline carrier or do you intend to do so in the next 12 months? If Yes, complete the Aviation Questionnaire (UW-AVIQ312). b) In the last 12 months, have you engaged in any hazardous sports (including, but not limited to, motorized vehicle racing, scuba or sky diving, parachuting, hang-gliding and mountain climbing), or do you intend to do so in the next 12 months? If Yes, complete the appropriate uestionnaire. c) In the last 10 years, have you had your driver s license suspended or revoked?... d) In the last 2 years, have you refused to provide a breathalyzer sample, and/or have you had 2 or more highway traffic violations?... If Yes, provide driver s license number and provide reasons(s), date(s), type(s) of offence(s) in the Remarks section. e) In the last 10 years, have you ever been convicted of any criminal offence or fraudulent financial charges or do you have any charges pending? If Yes, provide reasons(s), date(s), type(s) of offence(s) in the Remarks section. f) In the last 5 years, have you ever been bankrupt and not received a discharge, or are you currently involved in a bankruptcy proceeding? If Yes, provide additional information in the Remarks section. Remarks Details of any Yes answers. If applicable, attach the appropriate completed uestionnaire(s). QUESTION # INSURED # DETAILS 18

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