APPLICATION Individual Insurance - UV Mutuelle

 
APPLICATION Individual Insurance - UV Mutuelle
APPLICATION
  Individual Insurance
UNDERWRITING REQUIREMENTS

                                                                           LIFE INSURANCE
               (EXCLUDING T-10 SUPERIOR+, T-20 SUPERIOR+, T-30 SUPERIOR+ FOR SUM INSURED $ 250,000 AND MORE)
                                                                           AGES
               AMOUNTS ( $ )
                                 0 to 15 16 to 35 36 to 40 41 to 45 46 to 50  51 to 55 56 to 60 61 to 65 66 to 70 71 to 75
                    0 -    24,999           1           1              1               1          1           1         2              2                3         4A
               25,000 -    49,999           1           1              1               1          1           T         2              2                3         4A
               50,000 -    99,999           1           1              1               1          1           T         2              2                3         4A
              100,000 -   150,000           1           T              T               T          T           T         3              4                4         5A
              150,001 -   250,000           1           T              T               T          T           T         4              4                5         5A
              250,001 -   500,000           1           T              T               T          3           4         4              5                5         5A
              500,001 - 1,000,000           13          4              4               4          4           5         5              5                5         5A
            1,000,001 - 2,000,000           13          4              4               4          5           5         5              5                5         5A
            2,000,001 - 5,000,000           13          4              4               5          5           5         5              5                7         7A
             More than 5,000,000            8           8              8               8          8           8         8              8                8         8A

           T-10 SUPERIOR+, T-20 SUPERIOR+, T-30 SUPERIOR+ FOR SUM INSURED $ 250,000 AND MORE
                                                                                                      AGES
               AMOUNTS ( $ )
                                           0 à 15           16 to 35        36 to 40       41 to 45          46 to 50       51 to 55         56 to 60       61 to 65
              250,000 -   499,999            13                4               4              4                   4            4                4              5
              500,000 -   999,999            13                4               4              4                   4            5                5              5
            1,000,000 - 2,000,000            13                4               4              4                   5            5                5              5
            2,000,001 - 5,000,000            13                4               4              5                   5            5                5              5
             More than 5,000,000                8              8               8              8                   8            8                8              8
                                                                                                                                           66 and over         8

                                                            INSURANCE CRITICAL ILLNESS
                                                                                                      AGES
               AMOUNTS ( $ )
                                           0 to 15          16 to 35        36 to 40       41 to 45          46 to 50       51 to 55         56 to 60       61 to 65
                      0 - 99,999                1              1               1              1                   1           9                9              9
                100,000 - 250,000               1              3               3              3                   3           9                9              10
                250,001 - 500,000            13                4               4              4                   4           10               10             10
                500,001 - 999,999            13                4               4              5                   5           11               11             11
                1,000,000 and over           13                6               6              6                   6           12               12             12

    LEGEND :
      T)   Tele interview, complete page 7                                         10) Paramedical, full blood profile, prostate specific antigen (for males)
      1)   Insurability Declaration                                                    and electrocardiogram
      2)   Paramedical                                                             11) Medical exam, full blood profile, prostate specific antigen (for males),
      3)   Paramedical with urine HIV                                                  electrocardiogram and chest-x-ray (for smokers and ex-smokers
      4)   Paramedical with full blood profile                                         since 2 years or less)
      5)   Paramedical with full blood profile and electrocardiogram               12) Medical exam, full blood profile, prostate specific antigen (for males),
      6)   Medical exam with full blood profile and electrocardiogram                  stress ECG and chest-x-ray (for smokers and ex-smokers since 2 years or less)
      7)   Paramedical with full blood profile and stress ECG                      13) At the discretion of the underwriter
      8)   C.O.D. application to be submitted to Head Office                       A) « Individuals over 70 years of age » questionnaire EQC082
      9)   Paramedical, full blood profile and prostate specific antigen
           (for males)
    To determine underwriting requirements, add up all applications submitted to UL Mutual or other insurance company that are currently pending
    as well as all policies issued within the last 12 months and still in force.

    UL Mutual reserves the right to request any additional requirements in relation to the risk assessment.

2
218 344 024
                                                                                      APPLICATION
                                                Life Insurance (if you check « life insurance » only the life insurance protections is applicable)
PART 1                                          Critical Illness (if you check « critical illness » only the critical illness protections is applicable)
     SECTION A

PROPOSED LIFE INSURED

1. Name                                                           First Name                                                                   Name at Birth

2. Civil Status                            3. Birth Province                                                               4. Birth Country                                            5. Sex       M         F
                     Y   Y    Y    Y   M    M   D        D
6. Date of birth                                                      7. Age at nearest anniversary                                                                    8. Save Age

9. Canadian Citizen           Permanent Resident                      American Citizen                  Tax Resident (other countries)                   TIN

10. Since when in North America?                                            11. SIN                                                                12. Non-Smoker                      Smoker

13. Current Address                                                                                                                              14. Since when?

      City :                                                                      Province :                                                             Postal Code

15. a) Tel      (        )             -                         (home) Tel (                       )                  -                       (work) Tel (              )              -               (cell)

      b) Email address
16. Currently Working?                   Yes            No                  If no, why?

17. Occupation                                                                            18. Since when?

19. Employer

20. Annual Income                                                                      21. If student, Academic level

 SECTION B
BENEFICIARY                                                                                                 Assignee            Yes       No        If yes, please complete the form (EQC036).
Life Insurance and Critical Illness : Upon the death of the proposed life insured, I designate as beneficiary :
                                                                                                            Beneficiary                          Additionnal                 Contingent
1.                                                                                           %              5.                                                                                            %
2. Relationship to the insured                  3. Date of birth                                            6. Relationship to the insured                     7. Date of birth
                                                    Y        Y    Y     Y     M   M    D    D                                                                      Y     Y     Y   Y        M   M   D     D

* 4. Revocable               Irrevocable                                                                    8. Revocable                  Irrevocable
* NOTE: In the province of Quebec, in the absence of choice on questions 4 and 8, a married or civil union spouse designation is irrevocable and
        any other beneficiary designation is revocable. The contingent beneficiary designation is always revocable.

Critical Illness : Any claim as a result of a covered condition or illness in the critical illness contract will be paid to the owner,
unless otherwise indicated herein :
                                                             Claim recipient during the insured’s life                                                     Relationship to the insured
     SECTION C
OWNER          (to be completed if the owner is not the proposed life insured)                                                                   Tel (         )               -                    (home)
               If company, please complete the form (EQC088).
1. Name                                                                                     First Name                                                                         2. Sex           M             F
                                                                                                Y       Y        Y     Y    M   M     D    D
3. SIN                                                                4. Date of birth                                                              5. Insurance Age

6. Canadian Citizen           Permanent Resident                        American Citizen                             Tax Resident (other countries)            TIN

7. Current Address                                                                                                                                         Postal Code

8. Occupation                                                                                           9. Employer

10. Currently Working         Yes          No           11. Relationship

12. Civil Status                                          13. Birth Province                                                               14. Birth Country

15. Contingent Owner              Name                                                                                                First Name
                                                                                                                                                                                                                  3
218 344 024
    PART 1 (continued)                                            APPLICATION FOR LIFE OR
                                                                 CRITICAL ILLNESS INSURANCE

     SECTION D
    CHILD RIDER (LIFE INSURANCE)                   YES          NO
    If yes, please complete Part 2 CHILDREN SECTION ‘’Insurability declaration for Child Rider (Life Insurance)’’ (p.8)

                                1. Children                          2. Date of Birth             3. Height                    4. Weight                   5. Sex             6. Academic
                   Name                       First Name                yr/mo/day            ft. in.     m. cm              lbs        kg                                         Level

    7. Beneficiary upon the death of the children                                                                                              8. Revocable                   Irrevocable
    9. Relationship of the Owner or beneficiary to the children                     Father        Mother           Other

     SECTION E
                                      BASIC PROTECTION                                                                SUPPLEMENTARY BENEFITS
     1. a)                   FOR LIFE INSURANCE                                 SUM INSURED               2. a)        FOR LIFE INSURANCE
     • Adaptable               15    25   35  45                Chapter A      $
         (20 years payment                                                                                Waiver of premiums        In case of...
         minimum)              55    65   75  85
         Chapter B (Paid-Up Insurance)               $ ______________                                        Life Insured             Disability              Loss of Employment

                                                                                                             Owner                    Disability    Disab. or Death     Loss of Employment
      •T-10 Superior+
                                                                                                             Payer                    Disability    Disab. or Death     Loss of Employment
         Risk        Standard        Preferred           Super Preferred       $
                                                                                                             PAYER’S NAME _____________________________________________
     • T-20 Superior+
         Risk        Standard        Preferred           Super Preferred       $

     • T-30 Superior+                                                                                        A.D.D. $ ________________________ (Sum Insured)
         Risk        Standard        Preferred           Super Preferred       $

     • Integral                                                                $
                                                                                                             ACCIDENTAL FRACTURE
     •                                                                         $

     • Joint Insurance                 First to die                                                          PRE-APPROVED CRITICAL ILLNESS INSURANCE
                                                                               $
                                                                                                             Monthly Benefit $1000 up to 24 months
                                       Last to die

     (Each policy owner must sign each application.)

     1. b)                   FOR CRITICAL ILLNESS                                                         2. b)                 FOR CRITICAL ILLNESS
     • AdapCI                   15    25      35     45         Chapter A      $                          Waiver of Premiums           In case of...
         (20 years payment
         minimum)
                                55    65      75                                                             Life Insured             Disability               Loss of Employment
                                                                                                             Owner                    Disability    Disab. or Death     Loss of Employment
                                                                                                             Payer                    Disability    Disab. or Death     Loss of Employment
         Chapter B (Paid-Up Insurance)               $
                                                                                                             PAYER’S NAME      _____________________________________________________________
                                                                                $
                                                                                                             ACCIDENTAL FRACTURE

     SECTION
         ION F
    PREMIUM
    1. Multicontracts                  Yes                 No                        Ref. Application #/Policy #
    2. Premium Frequency               Annual              Monthly (P.A.D.)                        3.          Withdrawal Date (1 to 28 inclusive)
    4. Premium for the chosen premium frequency $                                                  5. Amount paid with application* $
                                                                                                        * for a maximum sum insured of $ 500,000

4
218 344 024
PART 1 (continued)

 SECTION G
EXISTING INSURANCE
IMPORTANT : 1. Insurance in force           Yes        No         If yes, complete the table and indicate life insurance, disability, credit, critical illness
                                                                  or long term care.

                2. Life Insured                3. Company             4. Month & year       5. Type of Insurance                  6. Sum Insured
                                                                          issued                (life or other)         Individual Ins.       Business Ins.

 SECTION H
SPECIAL INSTRUCTIONS
1. Conversion Policy #                                                          If irrevocable beneficiary/assignee : please have them sign at bottom of page 15
2. C.O.D. Application                  (No money taken)
3.

 SECTION I
     – Proposed life insured: to be completed at all times
     – Children: to be completed if child insurance is requested
     – Policy owner and payer: to be completed if benefits or riders are requested on either one

     HAVE ANY OF THE PERSONS TO BE INSURED BY THIS APPLICATION:                                                                                          YES     NO
     1.   Have any life, disability, credit, critical illness insurance, preferred risk or long term care application declined, modified
          or cancelled? (If yes, date, decision, company’s name and reason).
     2.   Intend to replace any existing insurance with this one? (If yes, company’s name and complete the “Replacement Notice
          form”) (see note 1 p. 15).
     3.   Have one or more applications pending in one or more companies? (If yes, amount, type of insurance, company’s name
          and will all the policies be settled?)
     4.   Had any application or insurance policy (life, disability, credit, critical illness, preferred risk, income or long term care)
          pending and/or cancelled in the last two (2) years? (If yes, company’s name, issue date and expiry date).

For all affirmative answers, please complete the following table:
     Quest. #            Date                  Reason                                      Appropriate details according to the question.

                                                                                                                                                                      5
6
The declarations in part 2

                                  of the application

                              do not need to be filled out

                      if a UL Mutual paramedical form

                      or a phone interview is required.

                     INFORMATIONS TELE INTERVIEW

E-mail * :

Phone number :            (        )           -

    cell. phone* :        (        )           -

When is the best time to contact you :
(please check all availabilities)
    Monday to Friday :                 8 am to 12 pm       12 pm to 3 pm
                                       3 pm to 6 pm         6 pm to 9 pm

    Saturday :                         9 am to 12 pm       12 pm to 3 pm

* Please note that if an e-mail address or cellular phone number is given, the procedures
  will be sent to the insured via e-mail or text message.
                                                                                            7
PART 2
                                                                                                                                          218 344 024
                                                           INSURABILITY DECLARATION

                                                                                                                            (Always complete if the Child Rider
     CHILDREN SECTION                                                                                                            (Life Insurance) is requested)

      Insurability declaration for Child Rider (Life Insurance)

                                                                                                                                                      YES   NO

      1.   Have any of the children to be insured by this application been declined, postponed or modified in any way? If yes, details (date, com-
           pany’s name and reason).

      2.   Were any of the children born prematurely for more than four weeks? If yes, details (number of gestation weeks at birth).

      3.   Are any of the children suffering from physical or mental impairment or have they had any illness, impairment or injury that has
           required a treatment or a surgery? If yes, details (type of impairment or disorder, starting and end date, treatment, doctor’s name and
           address).

      4.   Are any of the children currently taking medications or were they recommended to follow a treatment or to undergo diagnostic tests? If
           yes, details (name of the medication, dosage, tests, results, treatments, duration, recovering date, side-effect, doctor’s name and hos-
           pitals consulted).

      5.   Provide date, reason, results of the last medical consultation and the doctor’s name for each of the children.
           Date: _______________________________________________ Reason: ________________________________

           Results: _____________________________________________ Dr. Name:________________________________

    For all affirmative answers, please complete the following table:
       Quest. #            Date                      Reason                    Appropriate details according to the question.
     Child’s Name

                                                           INSURABILITY DECLARATION
                                                              (Life insured, policy owner and payer)
     SECTION A
      – Proposed life insured: to be completed at all times
      – Policy owner and payer: to be completed if benefits or riders are requested on either one

      HAVE ANY OF THE PERSONS TO BE INSURED BY THIS APPLICATION:                                                                                      YES   NO

      1.   Engaged in or intend to engage in flying other than as a commercial passenger? (If yes, complete the aviation questionnaire)

      2.   Engaged in or intend to practice hazardous activities (by ex: scuba diving, sky diving, race of car, motorcycle or boat, hang
           glider, ultralight, climbing or others)? (If yes, complete the appropriate questionnaire.)

      3.   Within the last 2 years, traveled outside North America or intend to do so in the future? (If yes, complete the foreign travel-
           ling questionnaire.)

      4.   Had a driver’s licence suspended or revoked or been charged of one or more driving violations in the past 5 years? (If yes,
           complete the driving history questionnaire.)

      5.   Been convicted of drunk-driving or driving under influence with blood alcohol level exceeding the legal limit or have such
           charges pending? (If yes, complete the driving history questionnaire.)
8
    For all affirmative answers, please complete the table on the next page.
218 344 024
PART 2 (continued)
                                                     INSURABILITY DECLARATION
                                                       (Life insured, policy owner and payer)

 SECTION A (continued)

  – Proposed life insured: to be completed at all times
  – Policy owner and payer: to be completed if benefits or riders are requested on either one

  HAVE ANY OF THE PERSONS TO BE INSURED BY THIS APPLICATION:                                                                            YES   NO

  6.   a) Currently drink alcoholic beverages? (If yes, indicate quantity.)
       Beer (bottle) _________/day_________/week Wine (glass):_________/day __________/week Alcohol (oz): _________/day_________/week

       b) Ever drank substantially more than outlined above? (If yes, indicate quantity)
       Beer (bottle) _________/day_________/week Wine (glass):_________/day __________/week Alcohol (oz): _________/day_________/week

       c) Ever received counselling or medical advice in relation to your alcohol consumption? (If yes, complete the Alcohol
       Questionnaire.)

  7.   Ever used heroin, morphine, cocaine, barbiturates, amphetamines, LSD, steroids, marijuana, cannabis, non prescribed
       Fentanyl or other drugs or narcotics? (If yes, complete the Drug Questionnaire.)

  8.   Currently smoke or smoked cigarettes, cigarillos, electronic cigarette, small cigars, cigars, pipe, chewing tobacco,
       Nicorette, nicotinic patch or tobacco in any other forms within the last 12 months? (If yes, provide the kind of tobacco
       and quantity per day)

  9.   Ever used any of the substances mentioned in 8. (If yes, when did you stop and for what reason?)

        NOTE: Any false declaration in relation to questions 7, 8 or 9 will automatically cancel the policy from issue date,
        without respect in the other legal motives for cancellation that the insurer can invoke.

  10. a) Been convicted of any criminal offences or criminal acts, or any criminal offences or criminal acts have been filed
         against them? (If yes, indicate the charges, date of conviction, parole date, etc.)

       b) Ever had financial difficulties? (If yes, provide details: consumer proposal, bankruptcy, the amount
          and discharge date).

For all affirmative answers, please complete the following table:
  Quest. #         Date                     Reason                                   Appropriate details according to the question.

                                                                                                                                                   9
218 344 024
     PART 2 (continued)
                                                           INSURABILITY DECLARATION
                                                         (Proposed life insured, policy owner and payer)

      SECTION B

     Life Insured:             Height:                        ft in.    Weight:              lbs   or Height:              m. cm    Weight:            kg

     Has your weight changed in the last year?        Yes       No     If yes, of how much and reason:
     To be completed if benefits or riders are requested on either one
      Policy owner :           Height:                        ft in.   Weight:               lbs   or Height:              m. cm    Weight:            kg
                               Height:                        ft in.    Weight:              lbs   or Height:              m. cm    Weight:            kg
     Payer :
     Has your weight changed in the last year?      Yes         No       If yes, of how much and reason:

     1. Name and address of the doctor who has your
        medical file (please indicate “not applicable”
        if that is the case):

      2. Date, reason and results of the last medical visit:

      3. Have you been referred to another doctor or another health professional or specialist whether he is a doctor or not?               Yes   No
       If yes, name and address:

       Date, reason and results:

     4. Within the past 24 months, did you take medications?            Yes          No      If yes, please complete the following table:

          Name of medication             Dose and frequency                       Reason                   Date started                Date stopped

     5. Complete the following table by considering the following illnesses: cerebrovascular or cardiovascular diseases (transient
        ischemic attack, cerebrovascular accident (stroke), cardiac disease, elevated cholesterol or others), cancer (specify the
        type), tumour, colon polyp, tuberculosis, cystic fibrosis, affection related to AIDS, diabetes, hypertension, polycystic kidney
        disease or other renal diseases, Huntington’s Chorea, Amyotrophic Lateral Sclerosis (ALS), motor neuron disease, multiple
        sclerosis, Alzheimer’s disease, dementia, muscular dystrophy, Parkinson's disease, hemophelia or any other hereditary disease.

     Always fill in the following table for all the family members even if they are in good health.

                                                                   Age at
               Relative            Current Health Status          Diagnosis   Current Age Age at Death                     Cause of Death

        Father

        Mother

        Brother (number)

        Sister (number)

10
218 344 024
PART 2 (continued)
                                                        INSURABILITY DECLARATION
                                                      (Proposed life insured, policy owner and payer)
 SECTION C

  – Proposed life insured: to be completed at all times
  – Policy owner and payer: to be completed if benefits or riders are requested on either one

  Within the past 5 years (applicable only to Section C):                                                                                             YES   NO

  1. a) Have you been under observation or received medical treatment or taken medications? (If yes, details.)

    b) Have you undergone diagnostic test , blood analysis , a test , an electrocardiogram                          , an X-Ray     , or any other
       additional tests ? (If yes, details and check the appropriate box.)

    c) Have you been hospitalised or undergone surgery? If yes, details (date, reason, results and treatment.)

    d) Have you ever been advised to undergo a diagnostic test , a test or an exam , be hospitalised                        or have surgery       ,
       even if it has not been completed? (If yes, details and check the appropriate box)

For all affirmative answers, please complete the following table:
   Quest. #            Date                       Reason                    Details: tests, results, treatment, duration, recovering date, side-effect,
                                                                            doctor’s names and hospitals consulted.

 SECTION D
  – Proposed life insured: to be completed at all times
  – Policy owner and payer: to be completed if benefits or riders are requested on either one

  1. Have you ever received care, consulted, been diagnosed or experienced symptoms relating to the following disorders (to                           YES   NO
     encircle if it is necessary):
       a) Ears, eyes, nose, mouth or throat disorder?
       b) Asthma, shortness of breath, emphysema, bronchitis, pneumonia, chronic obstructive pulmonary disease (COPD), blood spitting,
          tuberculosis, sleep apnea, sarcoidosis, cystic fibrosis or other respiratory or pulmonary disorder?
       c) Epilepsy, dizziness, fainting, tremors, convulsions, multiple sclerosis, optic neuritis, numbness, tingling, loss of balance, weakness of
          the extremities, sight disorder or feeling loss of the sight, Parkinson's disease, headaches, migraines, paralysis, memory disorder,
          dementia, senility, Alzheimer’s disease, muscular dystrophy, Huntington’s Chorea, transverse myelitis or other neurological or brain
          disorder?
       d) Chest pain, palpitation, arrythmia, high blood pressure, elevated cholesterol, rheumatic fever, heart murmur, cerebrovascular accident
          (CVA), transient ischemic attack (TIA), stroke, heart failure, angina, coronary artery disease, heart valve abnormality, bypass, blood
          clot, thrombophlebitis, cardiac surgery or other disorder of the heart, blood vessels or the circulatory system?
                                                                                                                                                                 11
218 344 024
     PART 2 (continued)
                                                               INSURABILITY DECLARATION
                                                             (Proposed life insured, policy owner and payer)

      SECTION D (continued)

       – Proposed life insured: to be completed at all times
       – Policy owner and payer: to be completed if benefits or riders are requested on either one

       1. Have you ever received care, consulted, been diagnosed or experienced symptoms relating to the following disorders: (to                               YES   NO
          encircle if it is necessary):
            e) Ulcerative colitis, Crohn's disease, bleedings, persistent diarrhea, polyp, diverticulitis, liver disorder, hepatic steatosis, hepatic cyst,
               hepatitis all types, hepatitis carrier, jaundice, pancreatitis, ulcer, gallstone or other disorder of the stomach, intestines, liver,
               gallbladder or pancreas?
            f) Sugar, blood, pus or protein in the urine, kidney stone, kidney cyst, renal infection, bladder infection, prostate infection, benign prostatic
               hypertrophy, abnormal level of the prostatic specific antigen (PSA), renal insufficiency, ovaries disorder, uterus disorder, abnormal
               cells of the cervix, hysterectomy, breast disorder (mass, lesion, lump or nodule), PAP test or abnormal mammography or other disorder
               of the kidneys, bladder or reproductive tract?
            g) Diabetes, disorder of thyroid gland, pituitary gland, lymphatic gland, hormonal gland, anemia, coagulation, hemophelia, hemochromatosis,
               platelet disorder, Epstein-Barr virus, bleeding, skin, lupus, sclerodermia or other disorder of the glands, blood or skin?
            h) Anxiety, depression, adjustment disorder, burnout, mood disorder, panic attack, suicidal idea or suicide attempt, schizophrenia,
               psychosis, chronic fatigue syndrome, attention deficit disorder, hyperactivity, eating disorder (bulimia, anorexia) or other psychiatric,
               emotional, mental or behaviour disorder?
            i) Disorder of muscle, bone, joint (hip, knee, shoulder), back or neck, ligament, rheumatism, arthritis, osteo-arthritis, gout, osteoporosis,
               fibromyalgia, chronic pain syndrome, amputation, degenerative disc disease, myasthenia gravis, post-polio syndrome or other
               musculoskeletal disorder?
            j) Acquired immunodeficiency syndrome (AIDS), or affection connected to AIDS (ARC) or any other deficiency of the immune system
               or undergone a test indicating the presence of the virus of the AIDS or antibody to the virus of the AIDS?

       2. Have you ever been operated for a cyst, tumour, mass, skin lesion, nodule, lump, naevus, mole, or a cancer or undergone treatments of
          radiotherapy or chemotherapy?

       3. Have you ever made a claim or received a pension, income replacement benefit, compensation following injury, sickness, accident or a
          handicap?

       4. Are you aware of any other symptom or health related disorder for which you have not yet consulted a doctor or received a treatment?

       5. Do you suffer from a hereditary disease, an incurable disease or a physical or mental handicap including intellectual deficiency?

       6. Do you suffer from a disease or an unspecified syndrome for which your doctor told you there is no treatment for?

       7. Does your spouse suffer or ever suffered from hepatitis B or C, or the AIDS or has ever received a positive result following a test of one
          or the other of these diseases?

     For all affirmative answers, please complete the following table:
        Quest. #             Date                        Reason                     Details: tests, results, treatment, duration, recovering date, side-effect,
                                                                                    doctor’s names and hospitals consulted.

12
218 344 024
PART 2 (continued)
                                                      INSURABILITY DECLARATION
                                                                (Proposed life insured)
 SECTION E
ADDITIONAL INFORMATION

                                                                ADAPCI CHILD
 SECTION F
1. Complete the following table by considering the following illnesses: cerebrovascular or cardiovascular diseases (transient ischemic attack,
   cerebrovascular accident (stroke), cardiac disease, elevated cholesterol, or others), cancer (specify the type), tumour, colon polyp, tuberculosis,
   affection related to AIDS, diabetes, hypertension, polycystic kidney disease or other renal diseases, Huntington’s Chorea, Amyotrophic
   Lateral Sclerosis (ALS), motor neuron disease, multiple sclerosis, Alzheimer’s disease, Parkinson's disease or any other hereditary disease.

   Always fill in the following table for all the family members even if they are in good health.
   Complete the grandparents’ portion only if the father and/or the mother are less than 40 years old.
      Relative            Current Health Status           Age at        Current Age      Age at Death                   Cause of Death
                                                         Diagnosis

    Father

    Mother
    Brother
    (number)
    Sister
    (number)
    Maternal
    Grandfather
    Maternal
    Grandmother
    Paternal
    Grandfather
    Paternal
    Grandmother

2. Has the person to be insured ever had or presents symptoms of any of the following diseases : heart disease, transient ischemic attack or
   stroke, cancer (specify the type), tumor, tuberculosis, infection related to AIDS, diabetes, hypertension, kidney disease, mental illness, alco-
   holism, Huntington’s Chorea, amyotrophic lateral sclerosis, motor neuron disease, muliple sclerosis, autism, muscular dystrophy, cerebral
   motor insufficiency, trisomy 21, cystic fibrosis, blindness, deafness, mutism, paralysis, Rett syndrom, congenital heart disease, hemophelia
   or any other hereditary disease?             Yes        No

   If yes, please give details :

3. If the person to be insured is less than one (1) year old, is he/she prematured for more than four (4) weeks?          Yes         No
                                                                                                                                                         13
218 344 024
     PART 2 (continued)
                                                                    ADAPCI CHILD

      SECTION F (continued)

     4. Does the parents of the person to be insured already owned a critical illness insurance?             Yes          No

        If yes, what is the sum insured?                Father :
                                                        Mother :

        If not, why?

     5. If the person to be insured has at least one brother or one sister, does his/her brother and/or sister had a critical illness insurance in force or
        in underwriting?      Yes          No
        If yes, what is the sum insured?                Brother :
                                                        Sister :

        If not, why?

14
218 344 024
                           AGREEMENT FOR THE ESTABLISHMENT OF A PERSONAL FILE
To ensure the confidentiality of your personal information including social insurance number, UL Mutual (The Union Life, a mutual assurance com-
pany) will establish a file for the purpose of providing you with insurance and other financial services. It will contain all information obtained at
the time of the application for insurance and of any insurance claim. The object of the file will be to enable UL Mutual to assess this application,
administer any policy that may be issued and appraise any risk or claim. Only authorized employees will have access to this file. You are entitled
to access the personal information in this file and, if applicable, to rectify any inconsistency. To do so, a written request must be sent to UL Mutual
Head Office at 142 Heriot Street, Drummondville (Québec) J2C 1J8.
                                         AUTHORIZATION TO OBTAIN AND RELEASE
                                        PERSONAL INFORMATION TO A THIRD PARTY
In order to assess insurability, maintain our file and claims assessment, we authorize any person or institution holding personal information about
us including any health information, medical history or eligibility for claims, to transmit such information to UL Mutual or its reinsurers upon
request. This includes doctors or other practitioners, hospital, medical clinic or paramedical companies, laboratories, insurance companies or
reinsurers, the MIB Inc., personal information agencies, financial advisors, any financial institution, the policy owner, our employer or previous
employer, the ‘’Commission de santé et sécurité du travail du Québec’’ or other Workmen’s compensation Board, Canada or Quebec Pension Plan,
‘’Société de l’assurance automobile du Québec’’ or other Department of Motor Vehicles, the ‘’Régie de l’assurance médicaments du Québec’’ or
other provincial Health Department, security and investigation agencies, claims and underwriting agencies, crime prevention or detection
agencies.

Likewise, we authorize UL Mutual to transmit the information to its reinsurers as well as to a third party. For the same purpose and to gather the
same type of information, we also authorize UL Mutual or its reinsurers to request an investigative report about us and to use information in their
possession in other files. This consent is also valid for gathering, use and transmission of personal information concerning our minor children.
No modification or alteration of this consent will affect its content nor bind the insurer. This consent may also be used for a request for additional
insurance or a contract modification.
                                                                DECLARATION
We, as the proposed life insured, the father/mother/legal guardian and the policy owner, declare having examined all the questions included in this
application. All answers given were correctly reproduced and are complete and true. Also, we authorize that they be used as the basis for the
insurance contract requested and we recognize that any false declaration or omission may void the insurance contract issued as a result of this
application.
We acknowledge that the insurance will take effect upon acceptance of the application by the Company as long as it was accepted without modifi-
cation, the first premium has been paid and no change has occurred in the insurability of any of the proposed insured since the signature of this
application.
We acknowledge having been notified that the financial advisor is to be paid by commission in relation to the transactions described in this
insurance application and that he is an independant worker and not the insurer’s representative.
We acknowledge to have examined the agreement for the establishment of a personal file.
We acknowledge to have read and received the notice of information disclosure.
A photocopy of this agreement shall be as valid as the original.
Note: If the names and first names in sections A and C of part 1 differ from the following signatures, the latter will appear on the contract.
Note 1 : I authorize UL Mutual to cancel the policies in force concerned by the replacement and listed in Part 1, Section I, Question 2 at the date
the insurance policy applied for is issued.
I understand that the illnesses covered by this insurance are limited to those described in the contract.
I hereby state that I am not an American citizen. However, in the case in which I would be an American citizen, my Taxpayer
Identification Number (TIN) can be found section A and C of part 1.
I have been informed the financial advisor is independent of the insurer and is not its representative.
I certify that the statements and answers contained in this application, if they were completed, and during the paramedical, telephone
interview and in any other questionnaire are complete and true and they are part of my life insurance or critical illness insurance appli-
cation and cannot be separated.

Signed at                                 Prov.                    this                      day of                                         20

X                                                                             X
            Signature of person to be insured (if 14 years or older)              Owner’s signature (if a company, duly appointed representative)

X                                                                             X
                Signature of father, mother or legal guardian                     Owner’s signature (if a company, duly appointed representative)
                    (if person to be insured is a minor)
X                                                                             X
                   Signature of Financial Advisor / Witness                                    Advisor’s / Witness’ name (please print)

                                                                 CONVERSION
As being owner/irrevocable beneficiary/assignee of the policy who will be transformed following the acceptation of this application,
I hereby aknowledge and accept the fact that I won't have any rights on the new policy.

X                                                                             X                                                                           15
    Signature of owner/beneficiary/assignee                                       Signature of owner/beneficiary/assignee
PRE-AUTHORIZED DEBIT (P.A.D.)                                                    218 344 024
     I authorize UL Mutual (The Union Life, Mutual Assurance Company) to issue cheques on my behalf and orders for payment of any nature, drawn
     from the financial institution hereby designated and payable to UL Mutual to clear the amounts due to UL Mutual for the insurance policy issued
     following the application identified by the number listed above.
                                                                                               unts due to UL Mutual for the insurance policy issued
     Name of the Financial Institution (FI)                                                                    IMPORTANT
                                                                                                               Attach a specimen cheque
     Branch Address
     Type of account       Cheque             Saving                      Type of Service     Personal          Enterprise
     Transit number                           Institution number                      Account number                               Day of Withdrawal
     Payment frequency          Monthly                Annual        Please take the first payment directly in the account : Yes       No

     It is implicit that the present document should be read in its plural form if the authorization is signed by more than one person.
     This authorization stays in force until UL Mutual has received from me a notice of modification or termination. This notice must arrive at least 10 busi-
     ness days before the date on which we debit the account, to the UL Mutual mailing address. I may obtain a cancellation form or more information on
     my right to cancel a P.A.D. by the payor by communicating with my financial institution or by visiting www.cdnpay.ca.
     UL Mutual is not allowed to transfer this authorization, directly or indirecty, by application of the law, by a change of control or otherwise, without gi-
     ving me at least 10 days notice.
     I have certain rights of appeal if a debit is not in conformance to the present agreement. For example, I have the right to get reimbursed any P.A.D.
     which had not been previously approved or is not compatible with the present P.A.D. agreement. To obtain a reimbursement form or for more infor-
     mation on my rights of appeal, I can communicate with my financial institution or visit www.cdnpay.ca.

     X
     N. B. : S’il s’agit d’un compte conjoint où plusieurs signatures sont requ
                                                                                     Date
               Signature of the person whose name appears on the cheques

     X                                                                            X
     N. B. : S’il s’agit d’un compte conjoint où plusieurs signatures sont requises, tous l   st
               Signature of the person whose name appears on the cheques                                            Owner’s signature

     N.B.: If this is a joint account where multiple signatures are required, all account holders must sign the authorization.

16
AUTHORIZATION — We, the undersigned,                                                                                                  218 344 024
1. Acknowledge having read and received the notice of information disclosure.
2. Authorize any doctor, health professional or institution according to the Health and social services legislations, insurance companies, MIB Inc.
   or any other agency, institution or person in possession of information about us or our health to transmit it to UL Mutual (The Union Life, Mutual
   Assurance Company) and its reinsurers.
3. Consent that a confidential report, including personal information in relation to our solvency, be requested regarding our request for insurance
   and we autorize that UL Mutual make a brief report of our personal health information to the MIB Inc.
4. Attest that this authorization remains valid as long as it is not revoked and after our deaths, we consent it to be given, as the case may be, by
   our heirs, executors or beneficiaries of the insurance policy issued, thereby renouncing in advance to the benefits of any legal disposition con-
   cerning professional secret and authorizing any person to transmit all information requested by UL Mutual.
5. We acknowledge that a photocopy of the present authorization shall be as valid as the original.

Signed at                                                           this                       day of                                                 20
X                                                                             X
         Signature of person to be insured (if 14 years or older)                  Owner’s signature (if a company, duly appointed representative)

X                                                                             X
         Signature of Financial Advisor                                           Signature of father, mother or legal guardian (if person to be insured is a minor)

AUTHORIZATION — We, the undersigned,
1. Acknowledge having read and received the notice of information disclosure.
2. Authorize any doctor, health professional or institution according to the Health and social services legislations, insurance companies, MIB Inc.
   or any other agency, institution or person in possession of information about us or our health to transmit it to UL Mutual (The Union Life, Mutual
   Assurance Company) and its reinsurers.
3. Consent that a confidential report, including personal information in relation to our solvency, be requested regarding our request for insurance
   and we autorize that UL Mutual make a brief report of our personal health information to the MIB Inc.
4. Attest that this authorization remains valid as long as it is not revoked and after our deaths, we consent it to be given, as the case may be, by our
   heirs, executors or beneficiaries of the insurance policy issued, thereby renouncing in advance to the benefits of any legal disposition concerning
   professional secret and authorizing any person to transmit all information requested by UL Mutual.
5. We acknowledge that a photocopy of the present authorisation shall be as valid as the original.
Signed at                                                           this                       day of                                                 20
X                                                                             X
         Signature of person to be insured (if 14 years or older)                  Owner’s signature (if a company, duly appointed representative)

X                                                                             X
         Signature of Financial Advisor                                            Signature of father, mother or legal guardian (if person to be insured is a minor)

                                                                                                                                                                        17
18
218 344 024
                                           CONDITIONAL INTERIM INSURANCE PROVISIONS
Received from                                                                             the amount of * $                        for an insurance
application submitted to UL Mutual (The Union Life, Mutual Assurance Company) and bearing the same number and the same date as this agreement.
* If the amount paid exceeds the premium for a life insurance or critical illness insurance of $500,000, the excess will be refunded.
Notwithstanding the terms and conditions in the application, if all conditions and restrictions listed below are fully complied with, the life insur-
ance or the critical illness insurance on the proposed life insured(s) takes effect on the latest of the following dates:
a) The date of the application,
or
b) The date of the last test and/or the last proof of insurability form required by the Company.

CONDITIONS AND LIMITATIONS
1) The above mentioned amount must be immediately cashable and must be at least equal to one monthly premium under this application.
2) The cheque to pay this application must be honored the first time it is presented for payment.
3) At the latest of a) or b) above, each proposed life insured must be insurable at standard rate, without extra premium or policy limitations or exclusions
   according to UL Mutual’s normal underwriting rules regarding the proposed policy.
4) The maximum amount payable under this agreement, any other similar agreement and other insurance in force with the Company is equal to
   the requested amount of life insurance or critical illness without exceeding a total of $500,000.
5) Any insurance under this agreement is subject to the terms and conditions of the proposed policy and will cease at the earliest of :
   a) The date that the insurance policy applied for is issued,
   b) 60 days from the issue date of this agreement,
   c) The date that a cancellation notice from the owner is received by the Company.
6) No life insurance or critical illness benefit will be payable under this agreement if the proposed life insured :
   a) Is less than 15 days old or 66 years old or more;
             or
   b) Has had an application or reinstatement request declined, postponed or accepted with an extra premium or limitation or exclusion at UL Mutual or elsewhere;
             or
   c) Was hospitalized during more than five (5) days during the last twelve (12) months;
             or
   d) Has committed suicide, made a false declaration, a non-disclosure or a fraudulent statement in the insurance application;
             or
   e) Has committed or has intended to commit or has tried to commit a criminal act.
7) Futhermore, no critical illness benefit will be payable if:
   a) The insured is diagnosed with cancer, as defined in the policy to be insured, or
   b) The insured is diagnosed with any other condition covered by the policy to be issued and doesn’t meet the survival period as defined in the policy.
No representative of the Company is authorized to modify any of the conditions or limitations stated above.
If one or more of the conditions or restrictions stated above are not fully complied with, the sole responsibility of the Company under this agreement
is to reimburse all premiums paid by the policy owner.
I have read and signed this agreement and I certify that all requested explanations were given to me by the financial advisor and are to my entire satisfaction.

Signed at                                                                       this                          day of                                                 20
X                                                                                           X
Signature of Financial Advisor                                                              Signature of Policy Owner

    IMPORTANT: PLEASE DETACH AND LEAVE WITH THE CLIENT IF THE ABOVE CONDITIONS AND LIMITATIONS ARE FULLY COMPLIED WITH.

                                                                                                                                                     218 344 024
                                                   NOTICE OF INFORMATION DISCLOSURE
Any life insurance request requires a gathering of information that must be as complete as possible. This information is of medical nature or in relation to your solvency.
In order to allow proper risk assessment for each of their insureds, most life insurance companies, including UL Mutual (The Union Life, Mutual Assurance Company), deal
with an organization named the MIB Inc., a non-profit organization which carries out an information exchange on behalf of its member companies.
All information relating to your insurability is treated confidentially. However, UL Mutual may transmit it to the MIB Inc.
If you submit a life or critical illness insurance request or if you submit a claim request to a member company, the MIB Inc. will provide that company, at its request, with the
information it has on you. If it receives a request from you, the MIB Inc. will make arrangements to provide you with the information in your file. If you doubt the accuracy of
the information from the MIB Inc., you may ask for rectification.
Here is the address of the MIB Inc.:
            MIB Inc.
            330, University Avenue, suite 501
            Toronto ON M5G 1R7
            Tel: (416) 597-0590
            www.mib.com
                                                    NOTE TO FINANCIAL ADVISOR — Remit this notice to the policy owner

                                                                                   NOTICE
In order to proceed with the analysis of your insurance application, it is possible that we will need to obtain additional information.
Investigation
A representative from an investigation company may contact you in order to get more personal and financial information.
Medical examination
A physician or a nurse from a paramedical organization may ask you to undergo a medical examination.
Tests
A physician or a nurse from a paramedical organisation or from a medical clinic may ask for a blood or urine sample. The test will focus on the presence of
many possible abnormalities like cholesterol, diabetes, liver problems, the presence of medication, drugs, nicotine and AIDS detection. In order to take a
blood or urine sample, your consent will be required.
                                                                                                                                                                                    19
20
218 344 024
                                                        FINANCIAL ADVISOR’S REPORT
PART 3                                              (Will not be part of the insurance policy)
   THIS REPORT IS AN IMPORTANT SOURCE OF INFORMATION AND MUST BE COMPLETED CAREFULLY.

   SECTION A
   SOURCE OF THE SALE

   Client’s Request        Acquaintance/Friend           Offer to Client          Referred by a Client        Relatives      Relationship

   Other

   Client known since                                                                                      Present at signature        Yes      No

   SECTION B              (to be completed for all business insurance)
   The information requested hereafter is to verify that the amount of insurance being requested is appropriate in relation to the size of the com-
   pany and the level of responsibility held by the proposed life insured.

   1.      Purpose of Insurance:         Buy/Sell Agreement                Key Person              Loan Protection            Other

   2.      How many years has the Company been in existence?

   3.      Company’s net assets? $                                                      Company’s market value : $

   4.      Net profit for the last two (2) years.    $                                         $

   5.      Share (%) of the company owned by the person to be insured                                            %

   6.      What is the amount of business insurance held by each of the partners?
                  Name of Partner                   Sum Insured       Share %                      Name of Partner                Sum Insured   Share %

   7.      Additional Comments

   SECTION C
   I have requested the following underwriting requirements

   from the following paramedical organization                                                                  Authorization Number

   SECTION D
   IDENTIFICATION OF FINANCIAL ADVISOR
               Last Name/First Name                  %         Financial                             Agency, if applicable                    General
                                                              Advisor Code                                                                   Agent Code

   SECTION E
   I confirm that I have stated to the policy owner the names of the companies that I represent, the possibility that I receive compensation (such
   as commission) and additionnal compensation (such as bonuses) and that I have no conflict of interest regarding the proposed transaction with
   UL MUTUAL or with the policy owner. Also, I confirm that the information received to complete sections A and C of Part 1 was verified through
   official and original documents.

   Signed at                                                               this                      day of                                     20

   Signature of Financial Advisor X
   • For speedier policy issue
     • Ensure that any correction is signed by the policy owner or the proposed life insured
     • Always use black ink in order to facilitate document photocopy
     • Never use liquid corrector in case of error
     • Never separate the application pages                                                                                                               21
22
WELCOME TO UL MUTUAL

                                                     YOUR MUTUAL LIFE INSURANCE COMPANY

Thank you for submitting an insurance application with us.

UL Mutual is a century-old mutual life insurance company in business since 1889 and its financial strength is
legendary. Its success is mainly due to sound business management and its well established distribution network.

When your application is accepted, you will automatically become a UL Mutual mutualist, offering you, among
others, the following advantages:

         -   the right to vote at the annual general meeting;
         -   the right to elect the board of directors.

For all your individual life insurance, commercial insurance and investment needs, the expertise of UL Mutual
and of your financial advisor is your guarantee of quality service.

                                                             Julie Michaud, ASA, M.A.P.
                                                             Senior Vice President
                                                             Individual Insurance and Investment & Retirement

Telephone: 1 800 567-0988
 UL Mutual is a member of Assuris.
Assuris is a non-profit organization that protects Canadian policyholders in the event that their life insurance company should become
insolvent.

                                                                                                                                         23
ULMUTUAL.CA

                          142 Heriot Street, Drummondville (Quebec) J2C 1J8
                    PHONE 819 478-1315 1 800-567-0988 FAX 819 474-1990
22-UL-2018-09
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