Section 1 –

Tell us your Name, and who will be Owner (usually they are the same).

Section 2 -

Tell us the amount of coverage you want to convert, and the type of coverage you would like. Let us know if you are disabled here. This is where you would let us know if you would like to apply for coverage over the amount you are eligible to convert. This would need underwriting.

Section 3 -

Be sure to answer the question on smoking.

Section 4 -

Complete all the questions in this section by answering the yes or no to see if you qualify for a premium discount.

Section 5 -

Who are you? This section refers to your identification.

Please attach a clear copy of a photo ID to the form when returned.

Section 6 -

Your beneficiary is the person or entity who receives the benefit in the event of your death. You may have multiple beneficiaries, if you choose. Generally, the owner of the policy, who is usually the same person as the life insured, may change the beneficiaries in the future provided the beneficiary designation is made revocable.  Unless you indicate otherwise, the beneficiary is revocable. The exception is in  Quebec, where if the beneficiary designation is made in favor of your married or civil union spouse, you specifically have to indicate it is revocable otherwise it is automatically irrevocable.

An irrevocable beneficiary is one which cannot be changed without the permission and signature of the beneficiary. Naming an irrevocable beneficiary will likely affect the rights you have under the policy.

If you do not know who you wish to name at this time, you may designate “Estate” as your beneficiary.

Section 7 –

Your beneficiary is who receives the benefit of the policy if you die. You can have multiple beneficiaries, if you like. The beneficiary can be revocable or irrevocable. The owner of the policy, usually the same as the life insured, can make changes to the policy as long as the beneficiary designation is revocable (in Quebec the default is irrevocable unless you tell us otherwise). If the designation is irrevocable, the signature of the beneficiary(ies) is needed.

If you do not know who you want to, you may have your “Estate” as your beneficiary.”

Section 8 -

Use this space for any additional information you wish to provide, for example, to list beneficiaries.

Section 9 -

You date and sign the form here. Make sure if the owner is different from the life insured that both of them sign.

Other forms

Client Identification form

We might need further proof of identification since we may not get to meet you face to face. This form provides that to us.

A commissioner of oaths or guarantor (see the list on the form) completes Section A and B, and signs in Section C.

Pre-Authorized Debit form

This form is completed when you change your banking from what was originally indicated on the application form.