A p p l i c a t i o n f o r a S i n g l e P r e m i u m Pa y o u t A n n u i t y Po l i cy

A p p l i c a t i o n f o r a S i n g l e P r e m i u m Pa y o u t A n n u i t y Po l i cy Registered and Non-Registered In this application, the terms you and your mean the owner of The Canada Life Payout Annuity Policy. The terms we, our and us mean The Canada Life Assurance Company. 1 of 6 : 188 CAN (01/12)

In which language would you like this policy to be issued? English French For a non-registered policy only - Have you applied for, or purchased a policy of life insurance within the past six months, or do you intend to apply for a policy of life insurance within the next three months? No Yes If this statement is not true, any annuity issued may be revised at Canada Life s discretion and may result in lower payments to the annuitant. Is the policy non-registered and is a third party involved with this policy? Consider if another individual or entity will give direction to the Owner regarding the purchase of this policy, paying premiums or making redemption requests OR will someone other than the Owner(s) sign the application on behalf of the Owner? No Yes If yes, the FSA is to complete the Third party section of this application. 1 Premium Information Cheque attached for $ Transfers Internal transfer from an existing policy (note that for funds transferring from a life insurance policy, a surrender form or letter of direction must be submitted with this application. (please complete transfer list below) Transfer from another carrier (please include copies of the required transfer forms) For RPP, LIRA or locked-in RRSP funds, please note that the pre-/post legislation splits will be required. If funds are locked-in, please provide the jurisdiction that the pension funds are locked-in under. (please complete transfer list below) TRANSFER LIST: For transfers from another carrier, please list the transferring institutions below with approximate amounts. For internal transfers, please indicate the existing contract number along with the approximate amounts. external carrier/internal policy no.: $ external carrier/internal policy no.: $ external carrier/internal policy no.: $ TOTAL $ Is the policy non-registered and the premium being applied $100,000 or more? No Yes If yes, complete Politically exposed Person Determination Form 17-8288 and submit with the application. 2 Request for Rate Guarantee Please fax your request to 1-800-690-6667 or locally at 519-435-6334 no later than midnight of the day following the day that the quote was produced. The terms and conditions of this rate guarantee can be found on page 5 of this form. Owner s Signature Date (d/m/y) 3 Primary Annuitant This is the person on whose life the annuity will be based. This person is also the Payee & Owner, unless otherwise stated in section 5 or 6. Your last name First name Initial Gender Social Insurance Number F M Your address (street, number and apartment) (If mailing address is a P.O. Box, General Delivery, or RR#, record civic address / physical location in Special Instructions section) City or Town Province Postal Code Date of birth (d/m/y) Occupation Acceptable proof of age must be submitted with this application. Line of Business 4 Co-Annuitant (Joint Annuity) Co-annuitant s last name First name Initial Gender Social Insurance Number F M Date of birth (d/m/y) Relationship to Primary Annuitant Acceptable proof of age must be submitted with this application. Occupation Line of Business 5 Owner Information Primary Annuitant or Primary and Co-Annuitant jointly (only available for non-registered funds) or Other (Complete section below) If Primary Annuitant IS NOT THE OWNER complete this section Last name/corporation name First name Initial Gender Social Insurance Number F M Address (street, number and apartment) (If mailing address is a P.O. Box, General Delivery, or RR#, record civic address / physical location in Special Instructions section) City or Town Province Postal Code Date of birth (d/m/y) Occupation Line of Business If the Owner is a corporation, non-corporation entity, or not-for-profit organization, additional information must be provided. Please complete Client Identity Verification section. Copy of this application and the Questionnaire for Owners which are Entities, Form 17-8289 and submit with the application. If the policy type is non-registered, complete the following Which valid document is being used to verify the Owner s identity: Document number: Birth Certificate Driver s License Passport Canadian government (federal or provincial) issued ID (please specify) Issue Date of Document (dd/mm/yyyy) Jurisdiction of Document (City, County, Province, Country) Expiry Date (dd/mm/yyyy) 2 of 6 : 188 CAN (01/12)

6 Payee (Select one) Primary Annuitant (Single Life) Joint Annuitants (primary annuitant and then to Co-Annuitant) Owner Joint Payees (Annuitants jointly, then to Survivor) Only available for non-registered funds If other, please complete below: Last name First name Initial Social Insurance Number Address (street, number and apartment) City or Town Province Postal Code (If mailing address is a P.O. Box, General Delivery, or RR#, record civic address / physical location in Special Instructions section) TRUSTEE FOR A CHILD If you have named a child as a payee and that child is a minor, you must also appoint a trustee. The trustee will receive any benefit payments that may become due while the child is still a minor. 7 Payment Information How would you like us to make our payments to you? (select one) Deposit to your bank account (please attach a blank cheque marked void or, if not available, complete the following banking information) Name & branch of your financial institution Your account number Your branch transit number If I select direct deposit, the Payee as indicated above, agrees to refund any amounts paid by Canada Life to which they are not entitled and the Payee directs the financial institution to return such amounts to us on our request. Cheque to be mailed to the Payee, as shown in section 6. 8 Policy Details Please attach the quotation which was produced for the annuity described below, and note any differences between the quotation and this application. Type of annuity: For locked-in RRSP, RPP or Locked-in Retirement Accounts, do you have a spouse as defined under the applicable legislation? No Yes: If yes and you are not selecting the minimum joint and survivor life annuity as defined under the applicable legislation, a spousal waiver form must be completed. Single Life with payments guaranteed Joint and Survivor Life with payments guaranteed Single Life with no income payments or other amounts to be Joint and Survivor Life with no income payments or other amounts to paid after the death of the Primary Annuitant if the death be paid after the death of both Annuitants if the death occurs after occurs after the first payment has been made *SIGN BELOW the first payment has been made *SIGN BELOW Single Life with Installment Refund Joint and Survivor Life with Installment Refund Single Life with Cash Refund Joint and Survivor Life with Cash Refund year Term Certain Annuity Other (describe fully) Term Certain to Annuitant s age 90 Reducing Payments (Applicable to Joint and Survivor Life Annuity) Term Certain to Spouse s age 90 No reduction on first death Spouse s date of birth dd/mmm/yyyy Reducing on later of first death and the end of the guarantee period to % of the annuity payment. Reducing on the later of the death of the Primary Annuitant and the end of the guaranteed period to % of the annuity payment. * I hereby acknowledge and understand that no income payments or other amounts are payable after the death of the Annuitant(s) under the policy, if the death occurs after the first payment has been made. I also understand that I may not designate a beneficiary under section 10 if this option is chosen. Signature of Owner: What date would you like your payments to begin? Choose any day between the 1st & the 28th (d/m/y) or one month after the date the funds are received. How often would you like to receive your payments? Monthly Quarterly Semi-annually Annually Subsequent income payments: Level Decreasing only once to $ on (d/m/y) (i.e. integrate with OAS and CPP/QPP for pension money only or OAS only). Increasing every year by % of the immediately preceding year s payment. NOTE: the maximum rate of increase is 4% for a registered policy and 6% for a non-registered policy. Death Benefit: (Payable if death takes place during the deferred period, before the First Payment Date) Return of Single Premium Return of Single Premium with % interest (to a maximum of 10%) on death of all annuitants. Income Payments to commence when due (for annuity certain plans only). No death benefit (applicable to single life or joint and survivor life annuities with no survivor and no guaranteed payments). No income payments or other amounts to be paid.*sign BELOW * I hereby acknowledge and understand that no income payments or other amounts are payable after the death of all Annuitants under the policy, if death occurs before any income payments begin. I also understand that I may not designate a beneficiary under section 10 if this option is chosen. Signature of Owner: 3 of 6 : 188 CAN (01/12)

9 Taxation For non-registered policies: I request Level Taxation (Prescribed Annuity), if applicable (not permitted for increasing annuities) I DO NOT want Level Taxation, and I understand the potential tax consequences. I request Accrual Taxation. I request Accrual Taxation in the deferred period and Level Taxation thereafter, if applicable. 10 Choosing Your Beneficiary The person you name below as the primary beneficiary, will receive your policy s death benefit if the annuitant dies. If the primary beneficiary dies before the annuitant does, the secondary beneficiary (if one is designated) will receive the death benefit. Should you wish to designate more than two beneficiaries, please either complete Form 584, Part C and attach it to this application or identify in Section 11 below. For applications signed in Quebec the designation of a spouse (married or civil union) as beneficiary is irrevocable unless you check the Revocable box below. For applications signed in all other provinces and territories a beneficiary is revocable unless you check the Irrevocable box below. Estate of last survivor of annuitant and any survivorship annuitant or REVOCABLE (Beneficiary may be changed by the Owner) IRREVOCABLE (I understand that the effect of my designating a beneficiary irrevocably is that while the beneficiary is living, I may not alter or revoke the designation without the consent of the beneficiary and I may not assign, exercise rights under or in respect of, surrender or otherwise deal with the contract without the consent of the beneficiary.) Primary beneficiary: Last name First name Relationship to You (owner) Contingent beneficiary: Last name First name Relationship to You (owner) Or No beneficiary (e.g. annuity has no guarantee) Trustee for beneficiary Only applicable where Quebec law does not apply If a trustee is appointed below, benefits to be paid under this policy to any beneficiary who, at the time payment is to be made, is a minor or is otherwise legally incompetent to give a valid discharge (according to the laws of the beneficiary s domicile), will be paid instead to the trustee, in trust for the beneficiary. Such payment will discharge Canada Life. The trust for any beneficiary will terminate once that beneficiary is both of age of majority and has legal capacity to give a valid discharge. The trustee is directed to deliver at that time, to the beneficiary, the assets then held in trust for that beneficiary. During the course of the trust, the trustee may apply trust assets for the support, maintenance, education, or other benefit of the beneficiary, and may exercise any right of the beneficiary under the contract, in the sole discretion of the trustee. Before completing this section, consider if you have already, in any document, made a trustee/administrator appointment which might apply. Consult with your legal advisor first. For Quebec only Benefits payable under this contract to a beneficiary who, at the time payment is to be made, is a minor, will be paid to his/her tutor(s), unless a valid trust has been established for the benefit of the minor, by will or by separate contract, to receive the benefits and we have been provided notice of the trust. If so, the trust should be named as the beneficiary in the section above, and the trustee should be named in the section below. Consult with your legal advisor first. Last name of trustee First name Relationship to You (owner) 11 Special Requests or Comments 12 Signatures By signing below, I acknowledge that I have had the opportunity to read and understand the application and the terms and conditions on the reverse. If you are signing on behalf of a corporation please indicate your title. Primary Annuitant s signature Signature of witness Dated at (city/prov.) Date (d/m/y) Co-Annuitant s signature Signature of witness Date (d/m/y) Owner s signature (if other than annuitant) Signature of witness Date (d/m/y) THE SECTION BELOW MUST BE SIGNED BY THE FINANCIAL SECURITY ADVISOR I certify that the identity of the Owner has been verified by reference to the Owner s birth certificate, driver s license, passport, or other Canadian government document (except as prohibited by law, which includes health cards in some provinces) indicated above as required by the Proceeds of Crime (Money Laundering) and Terrorist Financing Act. I certify that a) I have fully explained to the Owner the nature and effect of making an irrevocable designation of beneficiary b) the explanation was given to the owner not in the presence of the beneficiary, and c) the Owner indicated that he/she was aware of the irrevocable nature of the designation so made by him/her. d) For Quebec, I have fully explained to the Owner that where his/her spouse or civil union partner is named as beneficiary, the designation is automatically irrevocable unless he/she ticks the revocable box. I declare the application is complete and true to the best of my knowledge. I have provided the following information in writing to the Owner: a) the company or companies I represent; b) that I receive compensation (such as commissions or a salary) for the sale of life and health insurance products; c) that I may receive additional compensation in the form of bonuses, conferences, or other incentives; and d) any actual or potential conflicts of interest I may have with respect to this transaction. Primary Financial Security Advisor Name (Please PRINT) Agency Producer Code Secondary Financial Security Advisor Name (Please PRINT) Agency Producer Code Primary Financial Security Advisor s Signature Date (d/m/y) Secondary Financial Security Advisor s Signature 4 of 6 : 188 CAN (01/12)

What I Agree to When I Sign This Application By signing I confirm: the statements appearing in this application are true and are submitted as the basis for the policy to be made I am applying for a Canada Life Payout Annuity Policy and ask you to establish a policy as selected I understand the policy I have requested will not take effect until we have received your Single Premium and required documentation I understand that any amounts paid to me or my beneficiaries could be subject to income tax I authorize you to use my Social Insurance Number for identification, administrative and income tax reporting purposes in connection with my policy. if I have reserved an interest rate, I have read and agree to the interest rate guarantee agreement included with this application I accept any changes or additions noted in Section 11 I am aware of the implications should my answer to the question regarding applications or purchases of life insurance, located at the outset of this application, be inaccurate. Terms and Conditions for Rate Guarantees By signing in section 2 that a rate guarantee is requested, the Owner agrees to transfer the total amount of premium to The Canada Life Assurance Company. The Owner also acknowledges the commitment to transfer the funds is irrevocable. This agreement does not apply when funds within Canada Life are immediately available, such as funds from a DIA, RIB, FLEX, Generations or off-renewal transfer of a GIA, GII or RRIF. In these cases, the rate assigned will be a rate in effect on the date the transfer request is received. In order to hold the rate for non-registered funds, we will require the following no later than midnight of the day following the day that the quote was produced: a copy of the quote, signed application, including signature in section 2 and a copy of the cheque for the minimum, non-refundable deposit shown below. All items must be received, by fax, at our administrative office, in London, ON. Cheques for deposits should be made payable to Canada Life and be received in our administrative office, in London ON, within 3 days of receipt of the original fax. The entire premium must be paid in full by the end of the 45-day guarantee period. Deposit amounts as follows: 3% deposit required for premiums under $1 million 5% deposit for premiums $1 million or greater In order to hold the rate for 45 days for Registered funds, we will require the following no later than midnight of the day following the day that the quote was produced: A copy of the quote and signed application, including signature in section 2. All items must be received at our administrative office, in London ON. If the money is received by Canada Life more than 45 days after the date of this request, Canada Life has the right to give the less favourable of the rate basis in effect on the date of transfer and the guaranteed rate basis, but in no case will a more favourable rate than the guaranteed rate be given. If the actual amount received is greater than the estimated figure shown on this application by more than $5,000, Canada Life reserves the right to give the less favourable of the rate basis in effect on the date of the transfer and the guaranteed rate basis to the excess amount. This rate guarantee is not a guarantee of income but rather a guarantee of the rate basis used in the quotation. Note the rate basis is only one of the factors used to calculate the income or single premium. If the funds are not received on the exact policy date (i.e. effective date), Canada Life will re-quote based on the actual date of receipt, using the same guaranteed rate to determine the revised income or single premium amount but adjust the policy date to the date of receipt of payment. Personal information I understand that when I apply for any product or service, Canada Life establishes and adds to a confidential file that contains personal information concerning me. I have rights of access to, and correction of, this information. These rights may be exercised by writing to Ombudsman The Canada Life Assurance Company, at the address noted on page 6. The file is kept in the offices of Canada Life or in premises of a third party acting on behalf of Canada Life. Access to this personal information is limited to employees or persons authorized by Canada Life who require it to perform their duties, to persons to whom I have granted access, and as personal information may be collected, used, or disclosed in or from Canada or elsewhere, access may be had by persons authorized by laws of Canada or elsewhere, as applicable. I consent to Canada Life collecting, using, and disclosing personal information concerning me. I understand that Canada Life must obtain this information for the purpose of processing this application and, if approved, providing, administering and servicing the product(s) and/or service(s) applied for, advising me of products and services available from Canada Life, it subsidiaries, affiliates and strategic alliance partners, to help me plan for my financial security, investigating and processing claims, creating and maintaining records and fulfilling any purpose related directly to the preceding. Subject to legal or contractual restrictions, I may withdraw my consent at any time effective on receipt by Canada Life of my written withdrawal at Canada Life s head office or administrative offices. I understand that refusing to consent may result in my application being refused. I authorize the use of my social insurance or business numbers for tax reporting, identification and record keeping purposes. The parties hereto expressly wish the policy and all related documents be in English. Les parties aux présentes acceptent que la police et tous les documents s y rapportant soient rédigés en anglais I consent to Canada Life collecting, using and disclosing personal information concerning me from persons outside Canada Life including related companies and MIB, Inc formally known as the Medical Information Bureau, for the purpose of underwriting any annuity application. MIB Information MIB, Inc. is a not-for-profit membership organization of life insurance companies operating an information exchange on behalf of its members. I understand that if I apply to another MIB member company for life or health insurance coverage, or to which I have submitted a claim, MIB, upon request, will supply Canada Life with the information in its file. You may request a copy of your file by contacting MIB at MIB, Inc. 330, University Ave, Suite 501, Toronto, ON, M5G 1R7, Phone 416-597-0590. By signing this Application, I give you my consent to: 1. Obtain personal information about me from persons outside Canada Life (e.g. my financial security advisor, MIB, related companies), if this information is necessary for the purposes specified above, and 2. Disclose my personal information to your subsidiaries, affiliates, strategic alliance partners, service providers and my financial security advisor when disclosure is necessary for the purposes specified above. 3. Disclose my personal information to MIB as described in the MIB Information above Subject to legal or contractual restrictions, I may withdraw my consent by writing to the above address, however, absence of consent may affect\the services we are able to offer you. 5 of 6 : 188 CAN (01/12)

Please submit your application to: The Canada Life Assurance Company Attention: IRIS T424, 255 Dufferin Avenue, London, Ontario N6A 4K1 Third Party Determination The Proceeds of Crime (Money Laundering) and Terrorist Financing Act requires the existence of third parties affiliated with the policy, if any, to be determined and recorded. Please enter the information below. All required sections to be completed by advisor. If space is insufficient, use additional forms. Name: Date of Birth (dd/mm/yyyy) Relationship to owner/annuitant(s): Address (Address CANNOT be a P.O.Box, General Delivery, or RR number): Telephone number Occupation: Line of Business: If a corporation, registration number and country/province of incorporation (provide similar information for a non-corporate entity, e.g., partnership). If a third party is signing the application for the owner(s), the third party signer must be identified by valid government-issued identification, of the third party s choosing and must indicate the type of third party. Please enter the information below. attorney (power of attorney)/mandatary payor trustee executor collateral assignee/hypothecary creditor other Which valid document are you using to verify the identity? [complete all sections] Birth certificate Driver s license Document number: Passport Other ID, please specify*: Document issue date (dd/mm/yyyy) Jurisdiction of document (City, County, Province, Country) Document expiry issue date (dd/mm/yyyy) * Health card may not be acceptable document in all provinces. I cannot determine but have reasonable grounds to suspect there is a third party. (Describe grounds below) Client Identity Verification (Provide Owner Information in the Appropriate Category Below.) Canada Life will conduct a corporate search to verify the corporation s existence. Corporation or Non-corporate entity (For non-corporate entity, review partnership agreement or articles of association) Full legal name of corporation or non-corporate entity (e.g. association, partnership): Registration number (provide as much detail as possible) 1) Incorporation number (if available): 2) Other registration number: (If incorporation number not available, or for a non-corporate entity) Type of number: Jurisdiction of issue: Federal or Province/Territory of 3) Jurisdiction (of incorporation / formation) Federal or Province/Territory of Verifying existence: For corporate entities, the insurer will verify existence. If the owner is a non-corporate entity, the advisor must verify the entity s existence by referring to paper or electronic documentation (e.g. partnership agreement). Indicate if the documentation viewed was: on paper (attach a photocopy) or electronic (provide type and source) Type of electronic documentation (e.g. partnership agreement) Source of electronic documentation (e.g. web site; provide particulars) Signing official(s): (See Identification documents described in section 5 of the application.) Name Title Type of document Document number Place of Issue Document check list: Proof of age for annuitant(s) (e.g. birth certificate, passport, citizenship, etc.) A void cheque, for direct deposit A copy of the quotation Copies of the required transfer forms (e.g. RRIF T2030 form, Pension funds T2037 form) Please note that original transfer form should be sent to the transferring company and a copy should be forwarded to our administrative office. For internal transfers, please include the appropriate surrender form or letter of direction with original signatures. www.canadalife.ca The Canada Life Assurance Company The Canada Life Assurance Company Head Office 330 University Avenue Administrative Office 255 Dufferin Avenue Toronto Ontario M5G 1R8 London, Ontario N6A 4K1 6 of 6 : 188 CAN (01/12)