FULL APPLICATION FOR LIFE INSURANCE

Transcription

1 FULL APPLICATION FOR LIFE INSURANCE LIFE APP 08/2012

2 APPLICATION FOR LIFE INSURANCE PART 1 LIFE INSURED 1.(a) Name (print) Mr. Mrs. Miss Ms (b) Date of Birth (c) Age Nearest Birthday Day Month Year (d) Occupation (give details of duties) (e) Place of Birth (f) Social Insurance Number Province Country (g) Phone Numbers: Home - - Business - - SECOND LIFE INSURED JOINT LIFE INSURED OR APPLICANT FOR PREMIUM WAIVER, if any 2.(a) Name (print) Mr. Mrs. Miss Ms (b) Date of Birth (c) Age Nearest Birthday Day Month Year (d) Occupation (give details of duties) (e) Place of Birth (f) Social Insurance Number POLICYOWNER (if other than Life Insured) OR Province Country JOINT POLICYOWNER (Assumed with rights of survivorship unless otherwise noted in #8 below) 3.(a) Name (print) Mr. Mrs. Miss Ms (b) Date of Birth (c) Social Insurance Number Day Month Year (d) Relationship to the Insured(s) (e) Occupation (f) Phone numbers: H: ( ) B: ( ) Contingent Policyowner (for use if a Second Life or Child Protection Rider is being applied for or if the Life Insured is not the Policyowner) In the event of the death of the Policyowner, the Contingent Policyowner will be: Relationship 4. POLICYOWNER/MAILING ADDRESS Number and Street City Province Postal Code 5. IDENTITY VERIFICATION (only required for Universal Life applications) For each Insured/Owner, please submit one of the following*: Life Insured Second Insured Policyowner(s) Personal cheque (for the initial premium), or Pre-Authorized Debit agreement (if premiums will be paid via PAD), or Document Type: Document No.: From the original identity document (i.e. birth certificate, driver s license, passport etc.), complete details in the chart provided. Jurisdiction * Note: These requirements apply if the agent has personally met the client; otherwise, non face-to-face FINTRAC requirements apply. Additional Requirements for Corporations and other Entities: Please provide requirements as specified on the front page of the insert, in the ID Verification Information section. Not-for-Profit Organizations (in addition to the above): Is the entity a registered charity for income tax purposes? Yes No If No, does the entity solicit charitable donations from the public? Yes No 6. DETAILS OF POLICY BENEFITS Basic Amount Term 10 Riders & Benefits Term 20 Second Life 10 $ Disability Waiver Accidental Death $ RENEWABLE $ Term 30 Second Life 20 $ Applicant Waiver Child Protection $ TERM Term 10 Joint 1 st to Die* Second Life 30 $ Rider Term 20 Joint 1 st to Die* Term 30 Joint 1 st to Die* * Only Disability Waiver is available: First Life Second Life UNIVERSAL LIFE T-100 Basic Amount Please Riders & Benefits complete UL Term 10 $ Second Life 10 $ Disability Waiver Accidental Death $ Questionnaire $ on Page 9. Term 20 $ Second Life 20 $ Applicant Waiver Child Protection $ Term 30 $ Second Life 30 $ Rider Basic Amount Life Pay Riders & Benefits 15 Pay Term 10 $ Second Life 10 $ Disability Waiver Accidental Death $ $ 20 Pay Term 20 $ Second Life 20 $ Applicant Waiver Child Protection $ Term 30 $ Second Life 30 $ Parental Waiver Rider 7. PAYMENT OPTIONS: 8. SPECIAL INSTRUCTIONS Pre-Authorized Debit*: Monthly Semi-Annual Annual * COMPLETE PAGE 13 or Billing: n/a Semi-Annual Annual LIFE APP 08/2012 Page 1 of 13

3 PURPOSE OF THE INSURANCE 9. (a) What is the reason for purchasing the insurance?* Complete Sections: (b) Annual Incomes: PERSONAL Family Needs Loan/Mortgage Estate Taxes FG, FP Life Insured $ BUSINESS Buy/Sell Keyperson Creditor FG, FB OTHER: Second Life Insured $ * For applications of $1,500,000 or more, complete the Financial Questionnaire on page 10. BENEFICIARY 10. Beneficiary: The Beneficiary of any Child Protection Rider or Second Life Insured Rider will be the Policyowner unless otherwise specified. In the event of the death of any insured, the Beneficiary of any other life insurance will be: Relationship: Payment will be made in equal shares to beneficiaries who survive the Life Insured unless other percentages are indicated. A trustee should be named to receive proceeds on behalf of any minor Beneficiaries until a specified age. 11. Contingent Beneficiary: In the event of the death of all the Beneficiaries, the Contingent Beneficiary will be: Relationship: PERSONAL INFORMATION 12. Do any of the Proposed Lives Insured have any life insurance in force with this or other companies? YES NO If YES, complete the table below for all Proposed Lives Insured. Name of Insured Name of Company Issue Year Type of Insurance Purpose of Insurance Amount AD Amount Life Critical Illness Personal Business Life Critical Illness Personal Business Life Critical Illness Personal Business Life Critical Illness Personal Business 13. Does the policy being applied for involve REPLACEMENT of insurance with this or any other company? YES NO If YES, a LIFE INSURANCE REPLACEMENT DECLARATION signed by the applicant must be submitted. FOR ALL QUESTIONS ANSWERED YES, PROVIDE DETAILS IN SECTION Has the Life Insured, Second Life Insured or Applicant for Premium Waiver: (a) Applied for any life, disability or critical illness insurance within the last 6 months, or is any other application pending or contemplated? (b) Ever had any insurance company rate, decline, modify or postpone any application for or reinstatement of life, disability or critical illness insurance? (c) Any intention of changing duties or occupation? LIFE INSURED YES NO (d) Flown within the last two years, or any intention of flying, other than as a passenger on commercially scheduled airlines? If YES, complete Aviation Questionnaire on page 8. (e) Within the last two years, participated in any hazardous activities such as motor vehicle racing, parachute jumping, scuba diving, hang gliding, mountain climbing, or is such activity contemplated? If YES, complete appropriate questionnaire. (f) In the last 5 years used any tobacco or nicotine products including cigarettes, cigarillos, colts, cigars, pipes, chewing tobacco, snuff, nicotine gum or patches, or any form of nicotine substitute? If YES, provide details: LIFE INSURED TYPE AMOUNT OTHER LIFE TYPE AMOUNT In the last 12 months: YES NO YES NO In the last 2 years: YES NO YES NO In the last 5 years: YES NO YES NO OTHER LIFE YES NO 15. Is the proposed Life Insured a Canadian citizen or landed immigrant? (a) If NO, provide immigration status: (b) Have you resided in Canada for the last 12 months? If NO, provide previous country of residence and date of arrival to Canada. (c) Any plans to change country of residence or to travel outside of North America within the next 24 months? If so, please indicate location, purpose and intended length of stay in Section 21. LIFE APP 08/2012 Page 2 of 13

4 PERSONAL INFORMATION (CONTINUED) 16. Has there been any change in name in the last 5 years (marriage, etc.)? If YES, please provide previous names in Section Do you presently use alcoholic beverages? If YES, please complete the following: LIFE INSURED OTHER LIFE QUANTITY BEER WINE LIQUOR BEER WINE LIQUOR DAILY WEEKLY MONTHLY 18. (a) Are you now using or have you ever used the following drugs: Opium derivatives: heroin, morphine, Demerol, methadone? Barbiturates: Amytal, Phenobarbital, Seconal, Nembutal, Pentobarbital? Marijuana: hashish, cannabis? Amphetamines: Benzadrine, Dexedrine, Methedrine, Cocaine? Hallucinogens: LSD, DMT, Mescaline, Peyote, Psilocybin? Other: If YES, please give details: LIFE INSURED OTHER LIFE TYPE USUAL FREQUENCY QUANTITY OF USE DATES (From To) TYPE USUAL QUANTITY FREQUENCY OF USE DATES (From To) LIFE INSURED YES NO OTHER LIFE YES NO (b) Have you ever received treatment or been advised to seek treatment or medical advice because of your alcohol or drug usage? If YES, indicate date, name and address of any doctor, hospital or treatment center in Section 21. (c) Please add any additional information which you feel is important in Section Have you ever been convicted of a criminal offence or are any charges pending? 20. (a) Have you ever had your Driver s Licence suspended or revoked? (b) Have you ever been charged with driving while impaired or, within the last 10 years been charged with reckless driving or had more than 3 driving violations? (c) Do you have a valid Driver s Licence? If NO, provide details in Section 21. (d) Driver s Licence Number: LIFE INSURED Doc #: Jurisdiction: OTHER LIFE Doc #: Jurisdiction: 21. Question No. Name of Insured Details of YES Answers Above LIFE APP 08/2012 Page 3 of 13

5 IF A PARAMEDICAL OR MEDICAL EXAM IS REQUIRED, COMPLETION OF PART 2 (Q22-27) IS OPTIONAL. (PLEASE NOTE THAT THE UNDERWRITING PROCESS MAY BE FASTER IF PART 2 IS COMPLETED.) APPLICATION FOR LIFE INSURANCE PART NAME HEIGHT WEIGHT LIFE INSURED FULL NAME AND ADDRESS OF PERSONAL PHYSICIAN (where medical records are located) SECOND LIFE INSURED FOR ALL QUESTIONS ANSWERED YES, CIRCLE THE APPROPRIATE DISORDER AND PROVIDE DETAILS IN SECTION (a) Has any family member (whether now living or deceased) ever suffered from, or is suffering from, High Blood Pressure, Heart Disease, Stroke, Cancer or any other tumor (specify type of cancer or tumor), Diabetes, Polycystic, or other Kidney Disease, Mental Illness, Huntington s Chorea, Motor Neuron Disease (including ALS/Lou Gehrig s Disease), Multiple Sclerosis, Alzheimer s Disease, Parkinson s Disease or any other hereditary disease? (b) Please complete the following chart for ALL family members: LIFE INSURED YES NO OTHER LIFE YES NO LIFE INSURED DISEASE AGE AT DIAGNOSIS ACTUAL AGE, if living CONDITION, if living AGE AT DEATH CAUSE OF DEATH FATHER MOTHER BROTHER (1) BROTHER (2) SISTER (1) SISTER (2) OTHER LIFE DISEASE AGE AT DIAGNOSIS ACTUAL AGE, if living CONDITION, if living AGE AT DEATH CAUSE OF DEATH FATHER MOTHER BROTHER (1) BROTHER (2) SISTER (1) SISTER (2) 24. Has the Life Insured, Second Life Insured or Applicant for Premium Waiver ever been treated for, been advised to seek advice or treatment for or had any known indication of, or any disorder of: (a) THE EARS, EYES, NOSE, THROAT, LUNGS: including blood spitting, tuberculosis, pleurisy, sleep apnea, shortness of breath, persistent cough, asthma, bronchitis, impairment of hearing, speech or sight? If YES to bronchitis or asthma, please complete Bronchitis or Asthma Questionnaire on page 8. (b) THE HEART, ARTERIES OR OTHER PARTS OF THE CIRCULATORY SYSTEM: including angina, chest pain, elevated cholesterol, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack, peripheral vascular disease, or abnormal EKG? (c) CHOLESTEROL/BLOOD PRESSURE: (c)(1) Ever been on medication for high cholesterol? (c)(2) What is the most recent cholesterol reading, if known? (c)(3) Ever been on medication for high blood pressure? (c)(4) What is the most recent blood pressure reading, if known? (d) THE ABDOMINAL ORGANS: including ulcer, hernia, colitis, gallstones, Crohn s disease, diverticulitis, hepatitis, jaundice, liver disease, chronic diarrhea, pancreatic disease or intestinal polyps? (e) THE KIDNEYS, BLADDER, GENITAL ORGANS: including blood or pus or sugar or albumin in urine, stones, venereal or prostate disease? (f) THE BRAIN AND NERVOUS SYSTEM: including epilepsy, seizures, convulsions, stroke, transient ischemic attack (TIA), multiple sclerosis, numbness or tingling of limbs, dizziness or fainting spells, paralysis, Alzheimer s, Parkinson s, motor neuron disease (including ALS/Lou Gehrig s disease), coma, head injury, persistent headaches, depression, anxiety, panic attacks, or any emotional or nervous disorder? LIFE INSURED YES NO OTHER LIFE YES NO LIFE APP 08/2012 Page 4 of 13

6 APPLICATION FOR INSURANCE PART 2 (CONTINUED) (g) THE BLOOD AND GLANDS: including anemia, diabetes, leukemia, gout, allergy, night sweats, enlargement of lymph nodes (glands), breast disorder, unusual skin lesions or disorders or unexplained infections? (h) THE MUSCULO-SKELETAL SYSTEM: including arthritis, rheumatism, lupus, paralysis, deformity, amputation or other disorder of the muscles, bones or joints? (i) THE IMMUNE SYSTEM: including Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (A.R.C.), positive HIV test or any other immunological disorder? (j) Cysts, tumors, cancer, polyps, mole, lump or other growths, breast disorder or unusual discharge or abnormal mammogram or biopsy? 25. Other than as disclosed in the answers above, has any Life Insured, Second Life Insured or Applicant for Premium Waiver: (a) Consulted a doctor or medical practitioner within the last 5 years? LIFE INSURED YES NO OTHER LIFE YES NO (b) Had an EKG, Blood Tests or other diagnostic test in the last 5 years? (c) Been a patient in a hospital, sanatorium or other medical facility within the last 5 years? (d) Been advised to have any diagnostic test, hospitalization or surgery which has not been completed? (e) Ever been told had cancer, tumor or any other growth or malignancy? (f) Ever been tested for exposure to the AIDS virus? (g) Had any rapid weight loss within the last year? (h) Requested or received a pension, benefits or payment because of an injury or illness? (i) Had any health symptoms or complaints for which a physician has NOT been consulted or treatment received? 26. Is the Life Insured, Second Life Insured or Applicant for Premium Waiver currently under any treatment or medication? 27. USE THE FOLLOWING SECTION FOR DETAILS TO YES ANSWERS IN PART 2 OF THIS APPLICATION. QUESTION NUMBER PROPOSED INSURED DETAILS AS TO DIAGNOSIS, DURATION AND RESULTS DATE NAME AND ADDRESS OF PHYSICIAN AND/OR HOSPITAL LIFE APP 08/2012 Page 5 of 13

7 27. (continued) USE THE FOLLOWING SECTION FOR DETAILS TO YES ANSWERS IN PART 2 OF THIS APPLICATION. QUESTION NUMBER PROPOSED INSURED DETAILS AS TO DIAGNOSIS, DURATION AND RESULTS DATE NAME AND ADDRESS OF PHYSICIAN AND/OR HOSPITAL APPLICATION FOR INSURANCE FOR CHILDREN (Complete questions 28 33) (Completion of Part 1 Question 12 and 14(a) is also required) (INCLUDING THOSE COVERED UNDER THE CHILD PROTECTION RIDER) 28. Name of Insured under basic policy 29. CHILD S NAME BIRTHDAY BIRTHPLACE HEIGHT WEIGHT FULL NAME AND ADDRESS OF PERSONAL PHYSICIAN FOR ALL QUESTIONS ANSWERED YES, CIRCLE THE APPROPRIATE DISORDER AND PROVIDE DETAILS IN SECTION Has the child ever been treated for or had any known indication of, or any disorder of: YES NO (a) EARS, EYES, NOSE, THROAT, LUNGS: including blood spitting, tuberculosis, tumor, cyst, asthma, bronchitis, impairment of hearing or sight? If YES to bronchitis or asthma, please complete Bronchitis or Asthma Questionnaire on page 8. (b) (c) (d) (e) (f) (g) (h) HEART AND BLOOD VESSELS: including chest pain, palpitation, high blood pressure, rheumatic fever, heart murmur, heart attack, phlebitis? ABDOMINAL ORGANS: including ulcer, hernia, bleeding colitis, Crohn s disease, diverticulitis, hepatitis, jaundice, liver disease, tumor, cyst or chronic diarrhea? KIDNEYS, BLADDER, GENITAL ORGANS: including blood or pus or sugar or albumin in urine, stones, tumor, cyst or venereal disease? NERVOUS SYSTEM: including epilepsy, seizures, stroke, tumor, cyst, or mental, emotional or nervous disorder? BLOOD AND GLANDS: including anemia, diabetes, leukemia, gout, allergy, night sweats, enlargement of lymph nodes (glands), breast disorder, unusual skin lesions or disorders or unexplained infections? MUSCULO-SKELETAL SYSTEM: including disorder of the muscles, bones, joints, neck or back, paralysis or deformity? IMMUNE SYSTEM: including Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (A.R.C.) or any other immunological disorder? LIFE APP 08/2012 Page 6 of 13

8 APPLICATION FOR INSURANCE FOR CHILDREN (continued) 31. Other than as disclosed in previous answers, has any child: (a) Consulted a doctor or medical practitioner within the last 5 years? (b) (c) (d) (e) (f) (g) (h) (i) Had an EKG, blood test or other diagnostic test in the last 5 years? Been a patient in a hospital, sanatorium or other medical facility within the last 5 years? Been advised to have any diagnostic test, hospitalization or surgery which was not completed? Ever been tested for exposure to the AIDS virus? Had any rapid weight loss within the last 3 years? Been convicted of a criminal offense or are any charges pending? Had an application for life insurance declined, postponed or modified in any way? Been treated or counseled for alcohol or drug abuse? 32. Is any child currently under any treatment or medication? 33. USE THE FOLLOWING SECTION FOR DETAILS TO YES ANSWERS. QUESTION NUMBER NAME OF CHILD DETAILS AS TO DIAGNOSIS, DURATION AND RESULTS DATE NAME AND ADDRESS OF PHYSICIAN AND/OR HOSPITAL NOTE: Children actual age 16 and over must sign on page 12. TEMPORARY INSURANCE AGREEMENT QUESTIONS FOR TEMPORARY LIFE INSURANCE AGREEMENT For use with LIFE INSURANCE applications for Proposed Insureds who have not reached their 60 th birthday. The maximum coverage under the Life Temporary Insurance Agreement will be the lesser of either the amount of Life Insurance applied for or $1,000,000. No premium payment under the Life Temporary Insurance Agreement is accepted for a higher amount of life insurance. IF ANY OF THE FOLLOWING QUESTIONS IS ANSWERED YES OR IS LEFT BLANK, THE COVERAGE WILL NOT TAKE EFFECT UNDER THE LIFE TEMPORARY INSURANCE AGREEMENT AND THE AGENT DOES NOT HAVE THE AUTHORITY TO ACCEPT MONEY AND ISSUE THE LIFE TEMPORARY INSURANCE AGREEMENT AND RECEIPT. LIFE INSURED OTHER LIFE Have the Proposed Lives Insured: YES NO YES NO (a) (b) Within the last 2 years, had any known indication or treatment for heart disease or condition, chest pain, stroke, elevated blood pressure, cancer, diabetes, chronic kidney or liver disease? Ever had any known indication of or treatment for AIDS or tested positive for the HIV-virus? (c) (d) Ever had any application for life insurance declined? Consulted a physician or other practitioner within the past sixty days and been advised to have a further examination, diagnostic test or surgery not yet performed? LIFE APP 08/2012 Page 7 of 13

9 APPLICATION FOR LIFE INSURANCE CUSTOMER COPIES ADVISOR / BROKER PROCEDURES THE PAGES LABELED CUSTOMER COPIES 1, 2 AND 3 MUST BE GIVEN TO THE APPLICANT. TEMPORARY INSURANCE AGREEMENT AND RECEIPT The Receipt must be completed and Customer Copy 1 given to the Applicant if the following are satisfied: a) at least one month s premium is paid when the application is signed, * b) the proposed Life Insured is under age 60, AND c) all questions on the Notice Regarding Receipts and Life Temporary Insurance Agreement are answered NO. DO NOT collect any premium and DO NOT complete the Receipt if any of the above conditions are not met. WRITE VOID ACROSS THE ENTIRE CUSTOMER COPY 1 (RECEIPT AND TERMS). * FOR LIFE INSURANCE APPLICATIONS EXCEEDING $1,000,000: THE MAXIMUM COVERAGE UNDER THE LIFE TEMPORARY INSURANCE AGREEMENT WILL BE $1,000,000. ONLY THE PREMIUM REQUIRED FOR $1,000,000 OF INSURANCE CAN BE COLLECTED. NOTICES & DISCLOSURE STATEMENTS The Notice of Medical Information Bureau (MIB, Inc.) This notice must be given to every applicant. The Notice of Investigative Reports This notice must be given to every applicant. The Notice of Consent to Release Medical/Underwriting Information This notice must be given to every applicant. The Notice of Consent & Disclosure Regarding Personal Information This notice must be given to every applicant. Change in Insurability This notice must be given to every applicant. Policy Benefits Disclosure Statements If the plan being applied for is Universal Life, the Policy Benefits Disclosure Statements should be explained to the applicant. The same Policy Benefits Disclosure Statements are shown on Page 11 of the Application for Insurance. Advisor/Broker Disclosure Statement This section must be completed and signed by the selling advisor/broker. ID VERIFICATION INFORMATION (required under Anti-Money Laundering and Anti-Terrorism regulation) Requirements for corporations and other entities 1. Confirming existence existence must be confirmed by referring to the following documents: For corporations: certificate of corporate status, a record that has to be filed annually under the provincial securities legislation, or any other record that ascertains its existence as a corporation (e.g. Income Tax Return). For other Entities: partnership agreement, articles of association or other similar record. A copy of the confirming document must be forwarded to Wawanesa Life for record keeping. 2. Obtaining beneficial ownership information the following information must be obtained and sent to Wawanesa Life: Name and occupation of all directors of the corporation, and Name, address and occupation of all individuals who directly or indirectly own or control 25% or more of the shares of the corporation/entity. 3. Address of Life Insured provide address of Life Insured in the Statement by Agent section of the application LIFE APP 08/2012

10 RECEIPT Do Not Complete if C.O.D. RECEIVED $ FOR LIFE INSURANCE APPLIED FOR IN AN APPLICATION WITH THE SAME DATE AS THIS RECEIPT, ON THE LIFE/LIVES OF DATE SIGNATURE OF ADVISOR/BROKER TEMPORARY INSURANCE AGREEMENT (Limited Insurance Coverage) NO AGENT HAS AUTHORITY TO MODIFY OR WAIVE THE TERMS OR CONDITIONS OF THIS TEMPORARY INSURANCE AGREEMENT The Wawanesa Life Insurance Company agrees to insure the proposed Lives Insured named in the Application subject to the conditions and on the terms as set out below. CONDITIONS 1. Payment of the money must be made on or prior to the date of completion of the Application. 2. The amount paid must be at least equal to one monthly premium for the policy applied for. 3. Any cheque, draft, money order or other instrument tendered in payment must be honored upon the first presentation for payment. 4. Temporary Life Insurance will be effective only if questions (a), (b), (c) and (d) in the Notice Regarding Receipts and Temporary Insurance Agreement are truthfully answered NO by all the proposed Lives Insured. TERMS OF TEMPORARY INSURANCE AGREEMENT 1. Temporary Life Insurance under this agreement shall take effect on the Date of this Receipt. 2. No interim insurance coverage will be provided where the proposed Life Insured is, on the date of this agreement, either a) less than 15 days old, or b) 60 years of age or more. 3. If death is due to suicide, while sane or insane, the liability of the Company under this agreement will be limited to the return of the premium paid. 4. Subject to a maximum aggregate liability of $1,000,000 under this and all other temporary life insurance receipts in force at the death of the proposed Life Insured, the maximum amount payable under this receipt shall be the lesser of: a) the amount applied for, and b) $1,000, Any payment made by the Company under this agreement will be governed by the terms of the policy applied for and will be paid to the beneficiary shown in the Application. 6. Temporary Life Insurance under this agreement shall terminate on the earliest of the following dates: a) the date the policy applied for becomes effective, OR b) the date the Company mails notice to the Applicant that insurance under this agreement has been terminated, OR c) 60 th day following the Date of this Receipt. 7. If the Company accepts the Application as applied for without modification, the amount acknowledged in the Receipt will be credited toward the first premium due under the policy. If the Company issues a policy on a modified basis (e.g. with a rating), and the Applicant accepts the modified policy, the amount acknowledged in the Receipt will be credited toward the first premium due under the policy. If the Application is declined by the Company, or if the Applicant refuses a policy which is issued on a basis other than applied for, the amount acknowledged in the Receipt will be refunded to the Applicant. The Wawanesa Life Insurance Company Main Street Winnipeg, Manitoba R3C 1A8 Tel: FAX: [email protected] website: LIFE APP 08/2012 Customer Copy 1 of 3

11 NOTICES & DISCLOSURE STATEMENTS These notices and disclosures must be given to the Proposed Life/Lives Insured. NOTICE OF MEDICAL INFORMATION BUREAU, INC. (MIB) Information regarding your insurability will be treated as confidential. We, or our reinsurers may, however, make a brief report thereon to the Medical Information Bureau, Inc. (MIB), a non-profit membership organization of insurance companies which operates an information exchange on behalf of its members. If you apply to another MIB member company for life and health insurance coverage, or a claim for benefits is submitted to such a company, MIB, upon request, will supply such company with the information it may have in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB s file, you may contact MIB and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB s information office is 330 University Avenue, Suite 501, Toronto, ON Canada M5G 1R7, telephone number (416) We, or our reinsurers, may also release information in our file to other life insurance companies to whom you may apply for life and health insurance, or to whom a claim for benefits may be submitted. NOTICE OF INVESTIGATIVE REPORTS In the processing of the application for insurance, The Wawanesa Life Insurance Company may obtain Motor Vehicle Driving abstract/records, a personal investigation or consumer reports containing personal information about the individuals proposed for insurance. NOTICE OF CONSENT TO RELEASE MEDICAL/UNDERWRITING INFORMATION As part of the underwriting process, the Medical Director of Wawanesa may need to release medically related information obtained during the underwriting process to your personal physician or other medical practitioner. We may also need to disclose information regarding the underwriting factors to your Wawanesa Life advisor/broker. NOTICE OF CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION We collect, use and disclose your personal information in order to administer the products and services you have requested. Personal Information is collected for the purposes of: establishing and maintaining communications with you; underwriting risks on a prudent basis; investigating and paying claims; receiving payments of insurance premiums and policy loan repayments; withdrawing premiums from and depositing funds into your account (applicable if PAD Agreement is signed); detecting and preventing fraud; offering and providing products and services to meet your needs; compiling statistics and acting as required or authorized by law. We may share your personal information with the following people, organizations and service providers: Wawanesa Life employees and agents who require this information to perform their jobs; third party providers who require this information to provide their services to you, which may include paramedical agencies, underwriters, claims investigators, investigative agencies, providers of information processing and storage, programming, printing, mailing and distribution services; applicable reinsurance companies to allow them to evaluate and administer any insurance risk that the accept; the Medical Information Bureau as explained the notice provided; people to whom you have granted access; and people who are legally authorized to view your personal information. These people, organizations and service providers may be in other provinces or in jurisdictions outside Canada. Your information may be shared as required by the laws of those jurisdictions. There are other situations where we may share aspects of your personal information with others, as described below: We may share medical information collected about you with your doctor. We may share your personal information with an organization or person from whom we are collecting information about you, but only as required to obtain the information needed. If laboratory tests performed on our behalf show that you have tested positive for infectious diseases such as HIV or hepatitis, we may report this information to the appropriate public health authorities, as required. Because the medical information you include in this application becomes part of the printed contract, in the case of a corporate or joint policy, your medical information may be included in the policy contract issued to the policy owner(s) and any subsequent owners. In order to provide services to you in the future and provide you with the benefits included in the policy, Wawanesa Life may need to collect, use and disclose additional personal information about you. We may not require you to provide consent at that time. Any restriction or withdrawal of your consent may result in Wawanesa Life being unable to provide you with the product or service being applied for or having to terminate the policy. You can obtain further information about Wawanesa Life s Personal Information Protection Policy from the Wawanesa Life Head Office at Main Street, Winnipeg, MB R3C 1A8 or at CHANGE IN INSURABILITY If there is a change in insurability of any individual proposed for insurance subsequent to the completion of the application and before the policy is mailed to the Policyowner, The Wawanesa Life Insurance Company must be notified in order to properly evaluate the risk. If the change in insurability is not communicated and the Company is not given a chance to assess the risk, any policy issued pursuant to this application shall not take effect. Change in insurability includes: a change in occupation or lifestyle that would increase risks to the insured s life or health; any change that would cause the insured to answer health or lifestyle questions differently than when they applied for the insurance; the diagnosis or identification of any healthrelated condition; and any pending or completed medical tests or exams. POLICY BENEFITS DISCLOSURE STATEMENTS UNIVERSAL LIFE PLANS ONLY WAWANESA LIFE IS COMMITTED TO AN HONEST AND OPEN RELATIONSHIP WITH ITS CLIENTS. TO ACHIEVE THIS, WE ASK THAT YOU READ THE FOLLOWING DISCLOSURE STATEMENTS. THEY CONTAIN THE KEY ELEMENTS OF THE UNIVERSAL LIFE PLAN YOU HAVE CHOSEN AND OUR ADVISOR WANTS TO ENSURE THAT YOU HAVE A COMPLETE UNDERSTANDING OF YOUR PLAN. You acknowledge and understand that: 1. An illustration of the product applied for has been presented to you for review. 2. Investment returns for the purposes of the illustration have been chosen by you and are NOT GUARANTEED. 3. The account values and cash surrender values illustrated will change subject to fluctuation in future investment returns. 4. Variations in these factors will also impact any illustration in which it is projected that premiums may be discontinued at some future time. LIFE APP 08/2012 Customer Copy 2 of 3

12 ADVISOR/BROKER DISCLOSURE STATEMENT The following disclosure notice must be completed by the advisor/broker and provided to you, in writing prior to you entering into this financial transaction. Please ask your advisor/broker for further information or details. 1. I,, am a licensed insurance agent in the province of. 2. This transaction is between you and WAWANESA LIFE. 3. In soliciting this transaction, I am representing WAWANESA LIFE and. (Name of Agency) 4. In the past 12 calendar months, the majority of the insurance or financial products that I have sold were issued by the following companies:. 5. I am committed to selling on the basis of needs. 6. Upon completion of this transaction, I will receive compensation from WAWANESA LIFE and may receive additional compensation in the form of bonuses, conference programs or other incentives. 7. The nature and extent of my relationship with WAWANESA LIFE is as an independent insurance agent. 8. I and WAWANESA LIFE are prohibited from requiring you to transact additional business with WAWANESA LIFE or any other person or corporation as a condition of this transaction. 9. I declare the following conflicts of interest, if any: DATE SIGNATURE OF ADVISOR/BROKER LIFE APP 08/2012 Customer Copy 3 of 3 Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.

13 SUPPLEMENTARY QUESTIONNAIRES BRONCHITIS OR ASTHMA QUESTIONNAIRE B1. Do you suffer from, or have you ever suffered from bronchitis asthma other respiratory condition? If selected, please provide details: B2. When did you first have an attack? B3. How often do attacks occur? B4. What was the date of the most recent attack? B5. (a) Are the attacks Mild? Moderate? Severe? (b) Are they productive of sputum? YES NO (c) Have you ever coughed up blood? YES NO If YES, when? (d) Have you lost time from work? YES NO If YES, when? B6. Have you ever been hospitalized? YES NO If YES, when and where? B7. Are you under treatment or taking medication? YES NO If YES, what and how often? B8. Are your symptoms precipitated by seasonal changes, exercise, respiratory infections, etc.? YES NO If YES, please provide details: B9. Are you ever short of breath or do you wheeze on exertion? YES NO If YES, explain: B10. Have you ever had any tests or investigations carried out in connection to this condition; e.g. pulmonary function tests/spirometry, chest x-ray, etc.? YES NO If YES, please provide details: B11. Please provide dates, names and addresses of all doctors consulted: AVIATION QUESTIONNAIRE A1. Are you a pilot student pilot crew member? A2. As a pilot, student pilot or a crew member, please indicate: (a) the number of hours flown: hours (b) date of the last flight: (c) type of license currently held: Student Private Commercial Senior Commercial ATR N/A (d) do you hold a valid instrument rating? YES NO A3. Number of hours flown in the last: 12 months: hours months: hours A4. Number of flying hours contemplated in next 12 months: hours A5. Purpose of present and future flying: Pleasure Commercial Military Personal Business Other (specify): A6. Indicate category, class and type of aircraft flown: A7. Do you engage or expect to engage in student instruction, charter flying, freight carrying, sightseeing, photography, crop dusting, emergency services, prospecting, test or inspection flying? YES NO If YES, provide details: A8. Have you ever been involved in a flying accident or had your license restricted or suspended for any reason? YES NO If YES, provide details: A9. If aviation requires an extra premium or an exclusion rider, which would you prefer? Extra Premium Exclusion Rider SCUBA DIVING QUESTIONNAIRE S1. Do you dive for pleasure? YES NO or commercial purposes? YES NO S2. Do you engage in ice diving, night diving, search and rescue work, salvage diving, cave diving, free (apnea) diving or using underwater explosives? YES NO If YES, provide details: S3. What are the locations of your diving activities? lakes and rivers? ocean beaches? deep sea? other (specify): S4. Diving History (in feet) Last 12 months Next 12 months No. of dives Average time No. of dives Average time Less than and over S5. Do you dive alone? YES NO If YES, how often? S6. (a) Are you a certified diver? YES NO (b) Are you a member of an organized club? YES NO If YES, provide details: S7. Have you ever been involved in a diving accident that required medical attention? YES NO If YES, provide details: S8. If scuba diving requires an extra premium or an exclusion rider, which would you prefer? Extra premium Exclusion rider LIFE APP 08/2012 Page 8 of 13

14 SUPPLEMENTARY QUESTIONNAIRES (CONTINUED) UNIVERSAL LIFE QUESTIONNAIRE SECTION A BASIC INFORMATION TYPE OF COST OF INSURANCE: AMOUNT OF INSURANCE: UL SCHEDULED PREMIUM $ YRT TO AGE 100 $ SECTION B UNIVERSAL LIFE ILLUSTRATION ASSUMPTIONS ALL FACTORS ARE CHOSEN BY THE APPLICANT. How the Wawanesa Life Universal Life policy works: All premiums received, less any Premium Taxes, are deposited to the Daily Interest Account. An amount representing the Monthly Cost of Insurance and Monthly Administration Fee is withdrawn from the Daily Interest Account every month. The balance may be directed to any of the following Savings Options at your discretion: UNIVERSAL LIFE SAVINGS OPTIONS DAILY INTEREST ACCOUNT ALLOCATION OF SCHEDULED PREMIUMS* ASSUMED INVESTMENT RATES** GUARANTEED INVESTMENT ACCOUNTS INVESTMENT ACCOUNT ACCUMULATOR: When the balance reaches $250.00, an Investment Account for a term of years will be created. CANADIAN EQUITY INDEX-LINKED ACCOUNT INDEX-LINKED OPTIONS U.S. EQUITY INDEX-LINKED ACCOUNT INTERNATIONAL EQUITY INDEX-LINKED ACCOUNT CANADIAN BOND INDEX-LINKED ACCOUNT * For any option chosen, the minimum percentage is 5%. ** As chosen by the applicant for illustration purposes only. TOTAL 100% NET ILLUSTRATION INTEREST RATE % AUTOMOBILE AND MOTORCYCLE RACING QUESTIONNAIRE M1. Do you engage in automobile racing? YES NO and/or motorcycle racing? YES NO Type of vehicle used in races: M2. How many races did you enter in the past 12 months? the past months? and contemplate in the next 12 months? M3. What is the maximum speed attained? and average speed? M4. What type of racing or competition do you engage in? Examples Automobile: midget, sports car, stock car, championship, drag, sprint, etc. Motorcycle: hill climbing, cross country, drag, track, etc. M5. Indicate what type of track and surface is used: M6. Type of fuel used: M7. Purpose(s) of racing: Professional Amateur Both Please provide details: M8. Have you ever had an accident or injury arising from competition or practice that required medical attention? YES NO If YES, provide details: M9. If racing requires an extra premium or an exclusion rider, which would you prefer? Extra premium Exclusion rider LIFE APP 08/2012 Page 9 of 13

15 FG. FINANCIAL QUESTIONAIRE GENERAL INFORMATION (For applications of $1,500,000 or more) FG1. Please explain how the amount of insurance requested was determined: FG2. Have you, or any business you have been associated with ever been declared bankrupt? Life Insured: YES NO / Other Insured: YES NO If YES, please provide details: FP. FINANCIAL QUESTIONAIRE PERSONAL INFORMATION FP1. Financial Details: Life Insured Other Insured 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 FP2. Are you applying for personal loan protection? Life Insured: YES NO Other Insured: YES NO If YES, please provide details of loan including purpose and loan amount: FP3. Please provide any additional information you feel is important: FB. FINANCIAL QUESTIONAIRE BUSINESS INFORMATION FB1. Name of Business: FB2. Type of Business: Corporation Partnership Sole Proprietorship FB3. What is the current value of the business? $ FB4. Names of all partners or shareholders, NAME % SHARE if applicable: NAME % SHARE NAME % SHARE FB5. Are the other partners or shareholders: Presently insured? YES NO Requesting coverage now? YES NO FB6. Type of Insurance Creditor (go to Question FB7) Keyperson (go to Question FB8) Buy/Sell (go to Question FB9) FB7. Creditor Insurance (a) Purpose of loan (b) Names of borrowers (c) Name of creditor (d) Amount of loan $ (e) Was insurance requested by creditor? YES NO (f) Date loan applied for FB8. Keyperson Insurance (a) Name of position of the keyperson(s) (b) Please provide the following amounts for the most recent fiscal period ended: (c) For each keyperson, complete the following: Period ended: Salary Bonus Other Total Day Month Year Current Period Gross Income Net Income Retained Earnings Prior Period Current Period Prior Period FB9. Buy/Sell Insurance (a) Please provide the following amounts for the most recent fiscal period ended: Gross Income Net Income Retained Earnings Fair Market Value Current Period Prior Period Day Month Year FB10. Please provide any additional information you feel is important: LIFE APP 08/2012 Page 10 of 13

16 AGREEMENTS / DECLARATIONS / AUTHORIZATIONS AND SIGNATURES DECLARATIONS AND AUTHORIZATIONS I, the Life Insured/Second Life Insured/Policyowner understand and agree that: 1. Once the policy is issued and mailed to the Policyowner, the Policyowner will inspect the policy to verify that its terms are satisfactory and as requested. If the policy is not returned to Wawanesa Life within 30 days from the date the policy is mailed, the Policyowner accepts the policy. 2. No statement, representation or promise made in respect of the insurance applied for shall be deemed to have been communicated to or binding on Wawanesa Life unless set out in this application. 3. No agent is authorized to amend, alter, modify or waive the terms of this application, or any contract of insurance issued. 4. Except as provided in the Temporary Insurance Agreement, any policy issued pursuant to this application shall not take effect until: a) the policy is delivered, b) the first premium is paid and c) no change has taken place in the insurability of any individual proposed for insurance subsequent to the completion of the application and before the policy is mailed to the Policyowner. 5. Where existing Wawanesa Life insurance is to be replaced, the existing insurance is surrendered when this policy is in force. I declare that the statements and answers made in this application and in any supplement to this application are true, complete and correctly recorded and will form the basis of any contract issued. I acknowledge having received notices regarding The Medical Information Bureau and Investigative Reports, and consent to such reports being obtained by Wawanesa Life. I authorize Wawanesa Life, or its reinsurers, to make a brief report of my personal health information to The Medical Information Bureau. I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, The Medical Information Bureau, Motor Vehicle Department concerning my driver abstract, or other organization, institution or person that has any records or knowledge of me or my health or of my children or their health to give Wawanesa Life or its reinsurer(s) any such information. I authorize Wawanesa Life to perform such tests, examinations, x-rays, electrocardiograms, urinalysis, general blood profiles including blood tests for AIDS as may be required to medically underwrite this application for insurance. I authorize the Medical Director of Wawanesa Life to release all medically related information obtained during the underwriting process to my personal physician or other medical practitioner. I authorize Wawanesa Life to disclose information regarding the underwriting factors, if applicable, to my Wawanesa Life advisor/broker. CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION I consent to Wawanesa Life collecting, using and disclosing my personal information for the purposes of: establishing and maintaining communications with me; underwriting risks on a prudent basis; investigating and paying claims; receiving payments of insurance premiums and policy loan repayments; withdrawing premiums from and depositing funds into my account (applicable if PAD Agreement is signed); detecting and preventing fraud; offering and providing products and services to meet my needs; compiling statistics and acting as required or authorized by law. I have read and understood that Wawanesa Life may share my personal information with the required people, organizations and service providers as described in the Notice of Consent & Disclosure Regarding Personal Information on Customer Copy, who may be in other provinces or in jurisdictions outside Canada. My information may be shared as required by the laws of those jurisdictions. I recognize that in providing services to me in the future and providing me with the benefits included in the policy I am applying for, Wawanesa Life may need to collect, use and disclose additional personal information about me. I confirm that this consent applies to that personal information as well. I understand that any restriction or withdrawal of my consent may result in Wawanesa Life being unable to provide me with the product or service being applied for or having to terminate the policy. You can obtain further information about Wawanesa Life s Personal Information Protection Policy from the Wawanesa Life Head Office at Main Street, Winnipeg, MB R3C 1A8 or at TEMPORARY INSURANCE AGREEMENT DECLARATIONS (if applicable) I declare that the statements made in the Questions for Temporary Insurance Agreement are complete and true to the best of my knowledge and belief. I also declare that I have read The Temporary Insurance Agreement and understand the conditions and terms of the Agreement. UNIVERSAL LIFE DISCLOSURE STATEMENT (if applicable) I acknowledge and understand that: 1. An illustration of the product applied for has been presented to me for review. 2. Investment returns for the purposes of the illustration have been chosen by me and are NOT GUARANTEED. 3. The account values and cash surrender values illustrated will change subject to fluctuations in future investment returns. 4. Variations in these factors (2 & 3 above) will also impact any illustration in which it is projected that premiums may be discontinued at some future time. LIFE APP 08/2012 Page 11 of 13

17 AGREEMENTS / DECLARATIONS / AUTHORIZATIONS AND SIGNATURES (continued) PRE-AUTHORIZED DEBIT (PAD) AUTHORIZATION (if applicable please complete page 13) I request and authorize Wawanesa Life to make withdrawals from the account designated on page 13 of this application or from any subsequently designated account in order to make policy payments and/or specific payments on loan indebtedness, under the following terms: 1. Withdrawals will be made according to the payment frequency indicated on the application on the policy issue date unless a particular withdrawal day is specified. 2. If a monthly PAD is returned as insufficient funds, the next PAD amount will be for the two months of premium. Notification will be provided prior to this double withdrawal. 3. I may revoke my authorization at any time, subject to providing written notice of 10 days to Wawanesa Life. (For more information on your right to cancel a PAD agreement, contact your financial institution or visit 4. I have certain recourse rights, provided under the personal PAD agreement, if any debit does not comply with the agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with the personal PAD agreement. (For more information on your recourse rights, contact your financial institution or visit 5. I may provide written request to add/delete policies to the PAD agreement or change bank information without completing a new PAD agreement. 6. I waive the right to receive 10 days notice of an increase or decrease in the amount of the automatic withdrawal due to premium changes during the underwriting process. Notification of premium changes will be provided when the policy is issued. SIGNATURES I confirm that all of my answers to the declarations are truthful and complete to the best of my information, knowledge and belief. I further confirm that I have read, understood and accepted the terms and conditions of the agreements, declarations and authorizations contained in this application. A photocopy or an electronic reproduction of this document will be as valid as the original. Signed at in the province of. Date Life Insured, or parent if Life Insured is under age 16 (please print) Life Insured, or parent if Life Insured is under age 16 (signature) Second Life Insured (please print) Second Life Insured (signature) Policyowner, if other than Life Insured (please print) Policyowner (signature*) *Note: If Policyowner is a company, affix Company Seal and provide signature(s) of authorized signing officer(s). Child under Child Protection Rider, if age 16 or older (signature) PAD Account Holder(s), if other than the Life Insured/Policyowner (signature) Witness/Advisor/Broker (signature) LIFE APP 08/2012 Page 12 of 13

18 PRE-AUTHORIZED DEBIT (PAD) AGREEMENT You, the Payor, authorize the Wawanesa Life Insurance Company to debit the bank account identified below for the amount, frequency and on withdrawal day indicated or the next business day. For provisions of this agreement, please see the Pre-Authorized Debit Authorization section on page 12. PAYMENT FREQUENCY (check one) TOTAL MODAL PREMIUM WITHDRAWAL DAY MONTHLY SEMI-ANNUAL ANNUAL $ POLICY DATE OR (1 ST 28 TH ) PAYOR INFORMATION (please print clearly) ACCOUNT OWNER NAME(S) PHONE # STREET ADDRESS CITY AND PROVINCE POSTAL CODE BANK ACCOUNT INFORMATION Use my current Wawanesa Life PAD under policy # OR Establish a new PAD using: Details from premium cheque (attached) Details from void cheque (attached) Information provided below: FINANCIAL INSTITUTION (F.I.) BRANCH ADDRESS CITY AND PROVINCE POSTAL CODE TYPE OF ACCOUNT (must allow electronic debits) SAVINGS CHEQUING TRANSIT NO. F.I. NO. ACCOUNT NO. Note: Account Owner s signature is required on page 12. FOR HEAD OFFICE USE ONLY PAD NO. TOTAL PAD AMOUNT $ WITHDRAWAL DAY Attach a Void Cheque Here LIFE APP 08/2012 Page 13 of 13

19 STATEMENT BY AGENT TOTAL MODAL PREMIUM $ AMOUNT PAID WITH APPLICATION $ LIFE INSURED POLICYOWNER JOINT LIFE SECOND LIFE 1. (a) Address, if different from policyowner address: (c) Address, if different from policyowner address: (b) Years at this address: If less than 2 yrs, provide previous address in #8. (d) Years at this address: If less than 2 yrs, provide previous address in #8. 2. (a) Have you personally met the Life Insured? Yes No* * For UL policies non face-to-face anti-money laundering requirements apply. (b) How well do you know the Life Insured? New client Casually Well Related 3. (a) Employer s Name and Address: 4. (a) Does the Life Insured have any obvious physical impairment(s) or do you know of anything about the Insured that might affect the risk? Yes No 5. (a) Arrangements for Medical Requirements: Arrangements have been made by: Agent Branch Evidence ordered: Paramedical Medical Urinalysis Blood Profile EKG Name of paramedical facility: (c) Have you personally met the Policyowner/Second Life Insured? Yes No* * For UL policies non face-to-face anti-money laundering requirements apply. (d) How well do you know the Policyowner/Second Life Insured? New client Casually Well Related (b) Employer s Name and Address: (b) Does the Insured have any obvious physical impairment(s) or do you know of anything about the Insured that might affect the risk? Yes No (b) Arrangements for Medical Requirements: Arrangements have been made by: Agent Branch Evidence ordered: Paramedical Medical Urinalysis Blood Profile EKG Name of paramedical facility: 6. Mail policy to: policyowner (direct delivery) or agent (personal delivery) If no preference is indicated, policy will be mailed directly to policyowner. 7. FOR CHILDREN (a) Have you seen the child? Yes No (b) Does the child appear healthy? Yes No (c) Is the policyowner the child s parent? Yes No (explain in #9) (d) Does the child reside with the applicant? Yes No* (e) Are all children equally insured? Yes No (f) Amount of insurance on: Father $ Mother $ (g) If the parents are not insured, why is the child being insured? (Please give details in #8.) * If the child does not reside with the applicant, child s medical information must be obtained from the parent/guardian residing with the child. This parent s/guardian s signature is also required on page 12 of this application. 8. Please use the following section to provide details of the YES answers ( NO answers to Question 7) on the Statement by Agent. (Please provide any additional details that you believe are relevant to the underwriting of this application.) ALLOCATION OF THIS SALE FIRST YEAR RENEWAL % % AGENT OF RECORD (please print) Broker Number % % SERVICING AGENT (please print) Broker Number % % OTHER (please print) Broker Number AGENT S DECLARATION I declare that I have asked and fully recorded the answers of all proposed lives insured to all questions on this application, and that I know of nothing that is material to their insurability that has not been recorded herein. I am aware of and in compliance with the Company s Sales Code of Ethics. Confirming Disclosure: I have provided the applicant(s) with written materials advising: about the company(s) I currently represent; that I receive compensation (such as commissions or a salary) for the sale of life and health insurance products; that I may receive additional compensation in the form of bonuses, conference programs or other incentives; and of any conflicts of interest I may have with respect to this transaction. For Universal Life applications: I certify that a Universal Life illustration has been presented to the applicant in its entirety and it has been explained that the illustration is NOT GUARANTEED. SELLING AGENT (please print) LIFE APP 08/2012 SELLING AGENT (signature) Statement by Agent

20 Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.