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 5G1 1 800 913 8318 1. 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 18-80 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 $30,000 3. 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 00050 12-2014 5. 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 00049 11-2015 BW
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 www.cdnpay.ca 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 www.cdnpay.ca 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, e-mail privacy@westernlife.com or call 1-888-647-5433. 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
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 30,000 18 18 21 26 33 40 47 54 20 22 28 36 44 52 60 19 19 21 26 33 40 47 54 20 22 28 36 44 52 60 20 19 21 27 34 41 48 55 20 22 28 36 44 52 60 21 19 21 27 34 41 48 55 20 23 29 37 45 53 61 22 19 22 27 34 41 48 55 21 23 29 37 45 53 61 23 20 22 28 36 44 52 60 21 23 30 38 46 54 62 24 20 22 28 36 44 52 60 21 24 30 38 46 54 62 25 20 23 28 36 44 52 60 22 24 30 39 48 57 66 26 20 23 29 37 45 53 61 22 24 31 40 49 58 67 27 21 23 29 37 45 53 61 22 25 31 40 49 58 67 28 21 23 29 38 47 56 65 23 25 32 41 50 59 68 29 21 24 30 39 48 57 66 23 26 32 41 50 59 68 30 23 24 30 39 48 57 66 23 26 32 42 52 62 72 31 23 24 31 40 49 58 67 23 26 33 43 53 63 73 32 23 25 31 40 49 58 67 24 27 33 43 53 63 73 33 23 25 31 41 51 61 71 24 27 34 44 54 64 74 34 24 25 32 42 52 62 72 24 27 35 46 57 68 79 35 24 26 32 42 52 62 72 25 28 35 46 57 68 79 36 24 26 33 43 53 63 73 25 28 36 47 58 69 80 37 24 26 33 43 53 63 73 25 29 36 47 58 69 80 38 25 27 33 44 55 66 77 26 29 37 49 61 73 85 39 25 27 34 45 56 67 78 26 29 37 49 61 73 85 40 25 27 34 45 56 67 78 26 30 38 50 62 74 86 41 25 28 35 46 57 68 79 27 30 39 51 63 75 87 42 26 28 35 46 57 68 79 27 31 39 52 65 78 91 43 26 29 36 48 60 72 84 28 32 40 53 66 79 92 44 27 29 37 49 61 73 85 28 32 41 55 69 83 97 45 27 30 37 49 61 73 85 29 33 42 56 70 84 98 46 27 30 38 50 62 74 86 29 34 43 58 73 88 103 47 28 31 39 52 65 78 91 30 34 44 59 74 89 104 48 28 31 39 52 65 78 91 30 35 44 60 76 92 108 49 29 32 40 54 68 82 96 31 36 45 61 77 93 109 50 29 32 41 55 69 83 97 32 37 46 63 80 97 114 51 30 33 42 56 70 84 98 32 37 47 64 81 98 115 52 30 34 43 58 73 88 103 33 38 49 67 85 103 121 53 31 35 44 59 74 89 104 34 39 50 68 86 104 122 54 31 35 45 61 77 93 109 34 40 51 70 89 108 127 55 32 36 46 62 78 94 110 35 41 52 71 90 109 128 56 32 38 47 64 81 98 115 36 43 54 74 94 114 134 57 33 39 49 66 83 100 117 37 45 56 77 98 119 140 58 34 40 50 68 86 104 122 38 46 57 79 101 123 145 59 35 42 51 70 89 108 127 39 48 59 82 105 128 151 60 35 43 53 73 93 113 133 40 50 61 85 109 133 157 61 37 45 55 76 97 118 139 41 52 63 88 113 138 163 62 38 47 56 78 100 122 144 42 54 65 91 117 143 169 63 39 49 58 80 102 124 146 43 56 67 94 121 148 175 64 40 51 60 83 106 129 152 44 58 69 97 125 153 181 65 41 53 62 86 110 134 158 45 60 71 100 129 158 187 66 42 54 65 90 115 140 165 47 63 75 105 135 165 195 67 43 56 68 94 120 146 172 48 65 78 110 142 174 206 68 45 58 71 98 125 152 179 50 67 82 115 148 181 214 69 46 60 74 102 130 158 186 51 69 85 120 155 190 225 70 47 62 77 107 137 167 197 53 71 89 125 161 197 233 71 50 65 82 114 146 178 210 55 75 94 132 170 208 246 72 52 69 87 120 153 186 219 58 78 100 140 180 220 260 73 54 72 92 126 160 194 228 61 82 106 147 189 231 273 74 57 76 97 133 169 205 241 63 86 111 155 199 243 287 75 59 79 102 140 178 216 254 66 90 117 163 209 255 301 76 63 84 110 150 190 230 270 70 96 124 172 220 268 316 77 66 88 117 160 203 246 289 73 102 131 181 231 281 331 78 70 93 124 170 216 262 308 77 108 139 192 245 298 351 79 73 97 131 179 227 275 323 80 114 146 202 258 314 370 80 77 102 138 188 238 288 338 84 120 153 212 271 330 389 MALE * Age means age on the date coverage begins. Rates subject to change prior to purchase.
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 10,000 18 3,073 3,443 4,187 3,224 3,612 4,393 19 3,094 3,484 4,225 3,244 3,653 4,431 20 3,123 3,517 4,267 3,280 3,693 4,482 21 3,172 3,568 4,327 3,329 3,745 4,539 22 3,221 3,620 4,386 3,379 3,797 4,595 23 3,262 3,664 4,423 3,435 3,857 4,661 24 3,311 3,715 4,483 3,484 3,909 4,718 25 3,359 3,767 4,542 3,533 3,962 4,774 26 3,421 3,832 4,618 3,595 4,027 4,847 27 3,489 3,906 4,689 3,663 4,101 4,929 28 3,550 3,971 4,764 3,724 4,167 5,001 29 3,618 4,045 4,849 3,793 4,240 5,083 30 3,486 4,001 4,924 3,652 4,192 5,155 31 3,511 4034 4,964 3,686 4,235 5,216 32 3,536 4,066 5,018 3,720 4,278 5,277 33 3,561 4,099 5,058 3,754 4,321 5,338 34 3,587 4,132 5,112 3,789 4,364 5,399 35 3,612 4,165 5,166 3,823 4,408 5,460 36 3,638 4,198 5,206 3,857 4,451 5,521 37 3,663 4,231 5,261 3,891 4,494 5,583 38 3,689 4,264 5,301 3,925 4,538 5,644 39 3,714 4,297 5,356 3,959 4,581 5,706 40 3,740 4,331 5,396 3,994 4,624 5,768 41 3,777 4,387 5,450 4,034 4,686 5,827 42 3,814 4,444 5,504 4,075 4,748 5,887 43 3,851 4,501 5,571 4,115 4,809 5,947 44 3,888 4,557 5,626 4,156 4,871 6,008 45 3,926 4,614 5,681 4,197 4,932 6,069 46 3,963 4,670 5,735 4,237 4,994 6,130 47 4,000 4,727 5,791 4,278 5,056 6,191 48 4,037 4,784 5,846 4,319 5,117 6,253 49 4,075 4,840 5,902 4,360 5,179 6,315 50 4,112 4,897 5,957 4,400 5,240 6,378 51 4,153 4,958 6,059 4,449 5,311 6,495 52 4,194 5,019 6,160 4,497 5,382 6,611 53 4,235 5,080 6,273 4,546 5,453 6,728 54 4,276 5,141 6,375 4,594 5,524 6,845 55 4,317 5,203 6,476 4,642 5,595 6,962 56 4,370 5,340 6,570 4,691 5,733 7,051 57 4,423 5,475 6,663 4,741 5,869 7,138 58 4,476 5,609 6,757 4,790 6,003 7,226 59 4,529 5,741 6,838 4,840 6,136 7,313 60 4,582 5,872 6,930 4,889 6,266 7,399 61 4,650 6,021 7,077 4,953 6,414 7,537 62 4,717 6,168 7,212 N/A 6,560 7,674 63 4,784 6,312 7,358 N/A 6,703 7,812 64 4,850 6,455 7,493 N/A 6,845 7,949 65 4,916 6,597 7,638 N/A 6,985 8,086 66 4,964 6,692 7,838 N/A 7,073 8,285 67 N/A 6,787 8,033 N/A 7,161 8,478 68 N/A 6,881 8,223 N/A 7,249 8,667 69 N/A 6,975 8,419 N/A 7,336 8,852 70 N/A 7,069 8,602 N/A 7,423 9,032 71 N/A 7,219 8,813 N/A N/A 9,182 72 N/A 7,439 9,068 N/A N/A 9,367 73 N/A N/A 9,397 N/A N/A 9,638 74 N/A N/A 9,633 N/A N/A 9,802 75 N/A N/A 9,800 N/A N/A 9,900 76 N/A N/A 9,840 N/A N/A 9,920 77 N/A N/A 9,880 N/A N/A 9,940 78 N/A N/A 9,920 N/A N/A 9,960 79 N/A N/A 9,960 N/A N/A 9,980 80 N/A N/A 10,000 N/A N/A 10,000 www.everestfuneral.ca
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 Email 2 First and Last Name Telephone Email 3 First and Last Name Telephone Email 4 First and Last Name Telephone Email