application for quick issue critical illness · application for quick issue critical illness quci...

APPLICATION FOR QUICK ISSUE CRITICAL ILLNESS

QUCI 05/2017 of 5

GENERAL INFORMATION – INSURED

NAME (PLEASE PRINT) MR. MRS. MISS MS. DATE OF BIRTH AGE SEX

Last First Middle M F

DAY MONTH YEAR

INSURED ADDRESS – NUMBER, STREET, CITY, PROVINCE POSTAL CODE

PHONE NUMBER SOCIAL INSURANCE NUMBER OCCUPATION

PLACE OF BIRTH: PROVINCE: COUNTRY:

Has there been a change of name in the last five years? Yes No If YES: _________________________________________

Are you a Canadian citizen or landed immigrant, currently residing in Canada? Yes No If ‘No’, coverage is not available.

GENERAL INFORMATION – POLICY OWNER, if other than Insured

NAME (PLEASE PRINT) MR. MRS. MISS MS. DATE OF BIRTH AGE SEX

Last First Middle M F

DAY MONTH YEAR

POLICY OWNER ADDRESS – NUMBER, STREET, CITY, PROVINCE POSTAL CODE

PHONE NUMBER

SOCIAL INSURANCE NUMBER

POLICY OWNER OCCUPATION RELATIONSHIP TO INSURED

CONTINGENT POLICY OWNER

In the event of death of the Policy Owner, the Contingent Policy Owner will be: Date of Birth: DD/MM/YYYY Relationship:

BENEFICIARY

Beneficiary: In the event of death of the Life Insured, the beneficiary will be: Relationship to Insured

Trustee (if beneficiary is under age 18)

Contingent Beneficiary: In the event of the death of all the Beneficiaries, the Contingent Beneficiary will be:

Relationship to Insured

®


QUCI 05/2017 of 5

DECLARATION OF TAX RESIDENCE (only required for permanent cash value product applications)

(a) U.S. CITIZEN OR RESIDENT

Individual(s): Policy Owner Joint Policy Owner (if applicable)

Are you a U.S. citizen or a U.S. resident for U.S. tax purposes? Yes No Yes No

If ‘Yes’, provide your U.S. Taxpayer Identification Number (TIN):

Entities: Please complete the Declaration of Tax Residence for Entities form available on the Broker Forms page of our website.

(b) RESIDENT OF A COUNTRY OTHER THAN CANADA OR THE U.S. (required for policies issued after June 30, 2017)

Individual(s): Policy Owner Joint Policy Owner (if applicable)

Are you a tax resident of a jurisdiction other than Canada or the U.S.? Yes No Yes No

If ‘Yes’, give your jurisdictions of tax residence and taxpayer identification numbers (TIN).

If you do not have a TIN for a specific jurisdiction, give the reason using one of these choices:

Reason 1: I will apply or have applied for a TIN but have not yet received it.

Reason 2: My jurisdiction of tax residence does not issue TINs to its residents.

Reason 3: Other reason.

Jurisdiction of tax residence Taxpayer identification number If you do not have a TIN, choose reason 1, 2 or 3

Policy Owner

Joint Policy Owner

If reason 3 is selected, please specify:

Entities: Please complete the Declaration of Tax Residence for Entities form available on the Broker Forms page of our website.

Canadian financial institutions are required under Part XVIII and Part XIX of the Income Tax Act to collect the information you provide on this form to determine if we have to report your financial account to the Canada Revenue Agency (CRA). The CRA may share this information with the government of a foreign jurisdiction that a person identified on this form is a resident of for tax purposes. In the case of the United States, the CRA may also share the information with the U.S. government if the person is a U.S. citizen.

DETAILS OF POLICY BENEFITS PAYMENT OPTIONS (Select one)

Basic Amount T10 Renewable to 75 Level Term to 75 Level Term to 75 / ROP

Monthly Pre-Authorized Debit (PAD)* Semi-Annual PAD* Annual PAD*

* Complete PAD section on page 5

Semi-Annual Billing Annual Billing

$

POLICY DELIVERY OPTIONS

Policy should be mailed to: Policy Owner (direct delivery) or Independent Insurance Broker (personal delivery) If no preference is indicated, the policy will be sent directly to the Policy Owner.

®


QUCI 05/2017 of 5

TOBACCO USE

Within the last 12 months, have you used any tobacco or nicotine products including cigarettes, cigarillos, colts, cigars, pipes, chewing tobacco, snuff, e-cigarettes, nicotine gum or patches, or any form of nicotine substitute?

Yes No

QUALIFYING QUESTIONS

1. Within the last two years, have you had an application for individual life insurance or critical illness insurance

rated, declined, postponed or had exclusions added by Wawanesa Life or any other company? Yes No

2. Have you ever been treated for, diagnosed, consulted a doctor, received abnormal test results or experienced symptoms of the following:

(a) Heart attack, congenital cardiac defects, angina, angioplasty, coronary artery bypass, congestive heart failure, stroke, transient ischemic attack (TIA), arteriosclerosis or any other cerebrovascular disease or disease of the heart or the blood vessels, or an abnormal electrocardiogram (EKG)?

(b) Type 1 (insulin-dependent) diabetes or type 2 diabetes? (c) Cancer or other malignant disease, growth, tumour or colon polyp? (d) Multiple Sclerosis or motor neuron disease? (e) Any breast disorders (mass, cyst, unusual discharge, physical change, abnormal mammogram or biopsy)

or prostate disorders (nodule or abnormal PSA)? (f) Any eye or ear problems or diseases other than corrected by glasses, contact lenses or hearing aids?

Yes No

3. (a) Have you consulted a physician for an illness or condition which has not yet been diagnosed or for which

testing is still in progress? (b) Have you noticed any symptoms or health problems for which you have not yet consulted a physician,

such as: lump or mass of the breasts, shortness of breath, chest pain, dizziness, loss of balance, numbness, rectal bleeding, prostate or other problems?

Yes No

4. Have you ever tested positive for HIV or been diagnosed, treated for or had any indication of AIDS, AIDS

related complex, liver or kidney failure, cirrhosis, chronic kidney disease, hepatitis B or C, or carrier of hepatitis B?

Yes No

5. Within the last five years, have you received treatment or been advised to seek treatment or medical advice

because of your alcohol usage?

Yes No

6. Within the last five years, have you used: heroin, cocaine, hallucinogens or any other hard drugs other than as

prescribed by a doctor, or methadone whether prescribed by a doctor or not, or have you received treatment or been advised to seek treatment or medical advice because of your drug usage?

Yes No

7. To the best of your knowledge, has one of your natural parents or siblings ever suffered from, or are suffering

from heart disease, cancer, stroke or transient ischemic attack (TIA) prior to the age of 55?

Yes No

8. Does your current weight exceed the weight indicated in the maximum weight table below?

Height Weight Ft. in. cm. Pounds Kg 5’0” – 5’3” 150-162 200 91

5’4” – 5’6” 163-169 230 104

5’7” – 5’9” 170-177 250 113 5’10” – 6’0” 178-183 275 125 6’1” – 6’2” 184-188 290 132

Over 6’2” Over 188 315 143

Yes No

IF YOU ANSWERED ‘YES’ TO ANY OF THE ABOVE EIGHT QUESTIONS, COVERAGE IS NOT AVAILABLE. Note: Wawanesa Life reserves the right to carry out an assessment on factors other than the ones indicated above. Wawanesa Life also has a right to obtain a report from The Medical Information Bureau Inc. (MIB, Inc.) and, should this report be unfavorable, any premiums paid with the application will be refunded and coverage will not be in force during the investigation period.

®


QUCI 05/2017 of 5

DECLARATIONS AND AUTHORIZATIONS I, the Life Insured/Policy Owner understand and agree that:

1. Once the policy is issued and received by the Policy Owner, the Policy Owner 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 of the policy delivery letter, the Policy Owner 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 independent insurance broker is authorized to amend, alter, modify or waive the terms of this application, or any contract of insurance issued.

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 the notices regarding The Medical Information Bureau Inc. (MIB, Inc.) and Investigative Reports, and consent to such reports being obtained by Wawanesa Life. Should an unfavorable report be obtained from The Medical Information Bureau Inc. (MIB, Inc.), any premiums paid with the application will be refunded and coverage will not be in force during the investigation period. I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, The Medical Information Bureau Inc. (MIB, Inc.), Motor Vehicle Department concerning my drivers 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 independent insurance 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 and practices concerning service providers outside Canada from the Wawanesa Life Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at www.wawanesalife.com. If you have a question (including a question concerning our collection of personal information, or the collection, use, disclosure or storage of personal information by service providers outside Canada on our behalf) or complaint regarding our privacy policies or procedures, please contact the individual accountable for our personal information protection compliance: Senior Vice President, Chief Legal Officer & Corporate Secretary, The Wawanesa Life Insurance Company, 900-191 Broadway, Winnipeg, Manitoba R3C 3P1.

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 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 _________________________ on this ______ day of__________, ____________. _____________________________________________________ ________________________________________________________ INSURED (Signature) POLICY OWNER, if other than Insured (Signature) _____________________________________________________ ________________________________________________________ PAD ACCOUNT HOLDERS, if other than the Policy Owner WITNESS (Signature) or Insured (Signature)

AGREEMENTS / DECLARATIONS / AUTHORIZATIONS AND SIGNATURES ®


QUCI 05/2017 of 5 ®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.

PRE-AUTHORIZED DEBIT (PAD) (if applicable) (a) Bank Account Information

Use my current Wawanesa Life PAD under Policy #________________ or PAD#: __________________________ or

Establish a new PAD and use:

Details from initial premium cheque Details from VOID cheque (attached) Information provided below:

(b) Account Owner Name (c) Account Owner Address (if different from Policy Owner) (d) Phone No.

Transit # Fin. Inst. # Account # Branch Address Withdrawal date: Policy date or ____ (1st – 28th)

Note: Grace period starts from Policy date. If withdrawal date is after Policy date, grace period will be reduced.

PRE-AUTHORIZED DEBIT (PAD) AUTHORIZATION (if applicable) I request and authorize Wawanesa Life to make withdrawals from the account designated above 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 www.cdnpay.ca.) 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 www.cdnpay.ca.)

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.

ALLOCATION OF THIS SALE

ALLOCATION FACTORS

FIRST YEAR RENEWAL

_____________________________________________________ __________________ ________% _______% AGENT OF RECORD (Please print) BROKER NUMBER

_____________________________________________________ __________________ ________% _______% SERVICING AGENT (Please print) BROKER NUMBER

_____________________________________________________ __________________ ________% _______% OTHER (Please print) BROKER NUMBER

INDEPENDENT INSURANCE BROKER’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 or other incentives, and of any conflicts of interest I may have with respect to this transaction.

__________________________________________________________ _________________________________________________________

SELLING BROKER (please print) SELLING BROKER (signature)

AGREEMENTS / DECLARATIONS / AUTHORIZATIONS AND SIGNATURES (continued) ®

QUCI 05/2017 Customer Copy 1 of 2 ®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.

APPLICATION FOR INSURANCE CUSTOMER COPIES

®

INDEPENDENT INSURANCE BROKER PROCEDURES

THE PAGES LABELED CUSTOMER COPIES 1 AND 2 MUST BE GIVEN TO THE POLICY OWNER.

NOTICES & DISCLOSURE STATEMENTS

Receipt for Payment Receipt for Payment must be completed and given to the Policy Owner.

Independent Insurance Broker Disclosure Statement This section must be completed and signed by the selling independent insurance broker.

Change in Insurability This notice must be given to the Policy Owner.

The Notice of Medical Information Bureau Inc. (MIB, Inc.) This notice must be given to the Policy Owner.

The Notice of Consent to Obtain & Release Medical/Underwriting Information This notice must be given to the Policy Owner.

The Notice of Consent & Disclosure Regarding Personal Information This notice must be given to the Policy Owner.

RECEIPT FOR PAYMENT

RECEIVED $___________ FOR INSURANCE APPLIED FOR IN AN APPLICATION WITH THE SAME DATE AS THIS RECEIPT,

ON THE LIFE OF ____________________________________________________________________________________________________

_________________________________________________ _______________________________________________________

DATE SIGNATURE OF INDEPENDENT INSURANCE BROKER

INDEPENDENT INSURANCE BROKER DISCLOSURE STATEMENT

The following disclosure notice must be completed by the independent insurance broker and provided to you, in writing prior to you entering into this financial transaction. Please ask your independent insurance broker for further information or details.

1. I, ____________________________, am a licensed insurance broker 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 or other incentives. 7. The nature and extent of my relationship with WAWANESA LIFE is as an independent insurance broker. 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 INDEPENDENT INSURANCE BROKER

QUCI 05/2017 Customer Copy 2 of 2 ®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.

APPLICATION FOR INSURANCE CUSTOMER COPIES

CHANGE IN INSURABILITY If there is a change in insurability of any individual proposed for insurance subsequent to the completion of the application and prior to the date on the policy delivery letter mailed to the Policy Owner, 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 health-related condition; and any pending or completed medical tests or exams.

NOTICE OF MEDICAL INFORMATION BUREAU INC. (MIB, INC.)

Information regarding your insurability will be treated as confidential. We, or our reinsurers may, however, make a brief report thereon to MIB, Inc., a non-profit membership organization of insurance companies which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life and health insurance coverage, or a claim for benefits is submitted to such a company, MIB, Inc., upon request, will supply such company with the information it may have in its file. Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB, Inc.’s file, you may contact MIB, Inc. and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB, Inc.’s information office is 330 University Avenue, Suite 501, Toronto, ON Canada M5G 1R7, telephone number (416) 597-0590. 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 CONSENT TO OBTAIN & RELEASE MEDICAL/UNDERWRITING INFORMATION In the processing of the application for insurance, The Wawanesa Life Insurance Company may obtain records, investigative or medical reports containing personal information about the individuals proposed for insurance. 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 independent insurance broker.

NOTICE OF CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION We collect, use and disclose personal information in order to administer the products and services you have requested. Personal information is collected, used and disclosed 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 independent insurance brokers who require this information to perform their jobs; third party providers who require this information to provide their services, 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 they accept; the Medical Information Bureau Inc. (MIB, Inc.) as explained in 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 jurisdictions outside Canada. The information may be shared as required by the laws of those jurisdictions. 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 and practices concerning service providers outside Canada from the Wawanesa Life Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at www.wawanesalife.com. If you have a question (including a question concerning our collection of personal information, or the collection, use, disclosure or storage of personal information by service providers outside Canada on our behalf) or complaint regarding our privacy policies or procedures, please contact the individual accountable for our personal information protection compliance: Senior Vice President, Chief Legal Officer & Corporate Secretary, The Wawanesa Life Insurance Company, 900-191 Broadway, Winnipeg, Manitoba R3C 3P1.

THE WAWANESA LIFE INSURANCE COMPANY 400-200 MAIN STREET, WINNIPEG, MB R3C 1A8

PHONE 1-204-985-3940 TOLL FREE 1-800-263-6785 FAX 1-888-985-3872

®

application for quick issue critical illness · application for quick issue critical illness quci...

Documents