APPLICATION Individual Insurance - UV Mutuelle
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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.
2218 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
3218 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
4218 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.
56
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.
7PART 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.
9218 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)
10218 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?
11218 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.
12218 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
13218 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?
14218 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/assigneePRE-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.
16AUTHORIZATION — 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)
1718
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.
1920
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 2122
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.
23ULMUTUAL.CA
142 Heriot Street, Drummondville (Quebec) J2C 1J8
PHONE 819 478-1315 1 800-567-0988 FAX 819 474-1990
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