Application for Whole Life Insurance SIMPLIFIED ISSUE APPLICATION FORM

Transcription

1 Application for Whole Life Insurance Underwritten by Western Life Assurance Mail Application to: Everest Team, c/o HP Enterprise Services, 5150 Spectrum Way, Mailstop 4002, Mississauga, ON L4W 5G Your Health 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 inclusive who answered No to all of the health questions, please proceed. 2. Select Your Coverage $5,000 $7,500 $10,000 $15,000 $20,000 $25,000 $30, 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 Your Beneficiary (Required) 6. Payment Type (Select only one): Monthly Payments Payment Options (Select only one): Payment Amount and Date Single Payment (Client identification form required) Only available on $5,000, $7,500 and $10,000 coverage amounts. 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) 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) Mailing (Required if other than applicant) City Province Postal Code I understand that the initial payment will be debited as soon as administratively possible, and that monthly payments thereafter will be on or near the payment date I have selected. I understand that the effective date of this insurance policy will be 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 to be debited to the account or charged to the credit card. I request that the payments begin on and continue on approximately the same day of each month thereafter. Month / Day ** This plan is only available to residents of Canada excluding Quebec. Form #WLA BW

2 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. 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. 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 PAD Agreement, I may contact my financial institution or visit 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 pre-authorized debit (PAD) Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit 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 s personal information handling practices I may write to Western Life Assurance at P.O. Box 3300, Winnipeg MB R3C 5S2, [email protected] or call 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. 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 A G E N T 1 Agent s First Name City Agent s Code Agent s Last Name Province A G E N T 2 Agent s First Name City Agent s Code Page 2 - Simplified Issue Application Form Agent s Last Name Province

3 PREMIUM RATES FOR WESTERN LIFE SIMPLIFIED ISSUE WHOLE LIFE INSURANCE FEMALE Monthly Payments ($) AGE* 5,000 7,500 10,000 15,000 20,000 25,000 30,000 5,000 7,500 10,000 15,000 20,000 25,000 30, MALE * Age means age on the date coverage begins. Rates subject to change prior to purchase.

4 PREMIUM RATES FOR WESTERN LIFE SIMPLIFIED ISSUE WHOLE LIFE INSURANCE * Age means age on the date coverage begins. Rates subject to change prior to purchase. Single Payments ($) FEMALE MALE AGE* 5,000 7,500 10,000 5,000 7,500 10, ,073 3,443 4,187 3,224 3,612 4, ,094 3,484 4,225 3,244 3,653 4, ,123 3,517 4,267 3,280 3,693 4, ,172 3,568 4,327 3,329 3,745 4, ,221 3,620 4,386 3,379 3,797 4, ,262 3,664 4,423 3,435 3,857 4, ,311 3,715 4,483 3,484 3,909 4, ,359 3,767 4,542 3,533 3,962 4, ,421 3,832 4,618 3,595 4,027 4, ,489 3,906 4,689 3,663 4,101 4, ,550 3,971 4,764 3,724 4,167 5, ,618 4,045 4,849 3,793 4,240 5, ,486 4,001 4,924 3,652 4,192 5, , ,964 3,686 4,235 5, ,536 4,066 5,018 3,720 4,278 5, ,561 4,099 5,058 3,754 4,321 5, ,587 4,132 5,112 3,789 4,364 5, ,612 4,165 5,166 3,823 4,408 5, ,638 4,198 5,206 3,857 4,451 5, ,663 4,231 5,261 3,891 4,494 5, ,689 4,264 5,301 3,925 4,538 5, ,714 4,297 5,356 3,959 4,581 5, ,740 4,331 5,396 3,994 4,624 5, ,777 4,387 5,450 4,034 4,686 5, ,814 4,444 5,504 4,075 4,748 5, ,851 4,501 5,571 4,115 4,809 5, ,888 4,557 5,626 4,156 4,871 6, ,926 4,614 5,681 4,197 4,932 6, ,963 4,670 5,735 4,237 4,994 6, ,000 4,727 5,791 4,278 5,056 6, ,037 4,784 5,846 4,319 5,117 6, ,075 4,840 5,902 4,360 5,179 6, ,112 4,897 5,957 4,400 5,240 6, ,153 4,958 6,059 4,449 5,311 6, ,194 5,019 6,160 4,497 5,382 6, ,235 5,080 6,273 4,546 5,453 6, ,276 5,141 6,375 4,594 5,524 6, ,317 5,203 6,476 4,642 5,595 6, ,370 5,340 6,570 4,691 5,733 7, ,423 5,475 6,663 4,741 5,869 7, ,476 5,609 6,757 4,790 6,003 7, ,529 5,741 6,838 4,840 6,136 7, ,582 5,872 6,930 4,889 6,266 7, ,650 6,021 7,077 4,953 6,414 7, ,717 6,168 7,212 N/A 6,560 7, ,784 6,312 7,358 N/A 6,703 7, ,850 6,455 7,493 N/A 6,845 7, ,916 6,597 7,638 N/A 6,985 8, ,964 6,692 7,838 N/A 7,073 8, N/A 6,787 8,033 N/A 7,161 8, N/A 6,881 8,223 N/A 7,249 8, N/A 6,975 8,419 N/A 7,336 8, N/A 7,069 8,602 N/A 7,423 9, N/A 7,219 8,813 N/A N/A 9, N/A 7,439 9,068 N/A N/A 9, N/A N/A 9,397 N/A N/A 9, N/A N/A 9,633 N/A N/A 9, N/A N/A 9,800 N/A N/A 9, N/A N/A 9,840 N/A N/A 9, N/A N/A 9,880 N/A N/A 9, N/A N/A 9,920 N/A N/A 9, N/A N/A 9,960 N/A N/A 9, N/A N/A 10,000 N/A N/A 10,000

5 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 2 First and Last Name Telephone 3 First and Last Name Telephone 4 First and Last Name Telephone