Microsoft word - 89248 application ppi-ce may2009.doc

Life Insurance
Application
(05-2009)
® Registered trademarks of Royal Bank of Canada. Used under licence. COLLECTION AND USE OF PERSONAL INFORMATION
Collecting your personal information
We (RBC Life Insurance Company) may from time to time collect information about you such as: information establishing your identity (for example, name, address, phone number, date of birth, etc.) and your personal background; information related to or arising from your relationship with and through us; information you provide through the application and claim process for any of our insurance products and services; and information for the provision of products and services. We may collect information from you, either directly or through representatives. We may collect and confirm this information during the course of our relationship. We may also obtain this information from a variety of sources including hospitals, doctors and other health care providers, the MIB, Inc., the government (including government health insurance plans) and other governmental agencies, other insurance companies, financial institutions, motor vehicle reports, and your employer. Using your personal information
This information may be used from time to time for the following purposes: to verify your identity and investigate your personal background; to issue and maintain insurance products and services you may request; to evaluate insurance risk and manage claims; to better understand your insurance situation; to determine your eligibility for insurance products and services we offer; to help us better understand the current and future needs of our clients; to communicate to you any benefit, feature and other information about products and services you have with us; to help us better manage our business and your relationship with us; and For these purposes, we may make this information available to our employees, our agents and service providers, and third parties, who are required to maintain the confidentiality of this information. In the event our service provider is located outside of Canada, the service provider is bound by, and the information may be disclosed in accordance with, the laws of the jurisdiction in which the service provider is located. Third parties may include other insurance companies, the MIB, Inc., and financial institutions. We may also use this information and share it with RBC® companies (i) to manage our risks and operations and those of RBC companies and, (ii) to comply with valid requests for information about you from regulators, government agencies, public bodies or other entities who have a right to issue such requests. If we have your social insurance number, we may use it for tax related purposes and share it with the appropriate government
agencies.
Your right to access your personal information
You may obtain access to the information we hold about you at any time and review its content and accuracy, and have it amended as appropriate; however, access may be restricted as permitted or required by law. To request access to such information, or to ask questions about our privacy policies, you may do so now or at any time in the future by contacting us at: RBC Life Insurance Company
P.O. Box 246, Station A,
Mississauga, Ontario L5A 3A1
Attention: Director, Client Services
Telephone: 1-800-667-8910
Facsimile: 1-800-661-2794
Our privacy policies
You may obtain more information about our privacy policies by asking for a copy of our “Straight Talk®” brochure about privacy, by calling us at the toll free number shown above or by visiting our web site at www.rbc.com/privacy Guidelines for Completion of Application
Print legibly in blue or black ink.
Do not make erasures or use liquid paper. Do not use ditto marks. Stroke out an error and have the applicant initial it.
The application is a legal document forming part of the policy contract.
Ensure the latest version of illustration software – RBC Illustrations or Composer - is used as a reference.
This application is for life insurance and available benefits and riders only. Depending on the product, a critical illness,
long term care and disability rider may be added to the life component.
If the Proposed Life Insured is not fluent in English, a Statement of Understanding in the Proposed Life Insured’s
language of choice must be submitted with the application and is an underwriting requirement.
Other Standalone Products
•
For standalone disability and/or critical illness, complete the Disability and Critical Illness Insurance Application #83530. For standalone long term care, complete the Long Term Care Application #89606. TRIAL Applications
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Identify TRIAL on the cover of the application. Do not give out a Temporary Life Insurance Agreement (TIA) or order any Separate Quebec applications
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If this application is being written in Quebec or if the insured or applicant lives in Quebec, ensure you are using the correct application, #89250 for Quebec English, #89251 for the Quebec French version. Social Insurance Number
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This information is required for tax purposes. It need not be collected for Term policies. Policy Ownership
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Minimum legal age is 16 years except in Quebec where it is 18 years. Joint ownership will be set up with right of survivorship. This will ensure that upon the death of a joint owner, ownership will pass Minor Beneficiaries
•
If the beneficiary is a minor, we recommend that a trustee be appointed by completed the Appointment of Trustee form. This will avoid having to pay any proceeds into court. Revocable/Irrevocable Beneficiaries
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All beneficiaries are revocable unless the irrevocable box has been checked. Naming a minor as an irrevocable beneficiary should be avoided as the authorization of an irrevocable beneficiary is required for any change which impacts the value of the policy and a minor cannot give that authorization. Replacements
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If this new policy will result in the termination, modification or reduction in benefits of an existing policy within six months of this application, the Comparison Disclosure Statement must be submitted with the application and is an underwriting requirement. Travel
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In the Personal Information section, if the Proposed Life Insured has travelled within the last 2 years or has plans to travel outside Canada or the United States, the Travel Questionnaire must be completed. This can be printed from the PPI Associate website. Given the mobility of today's population, it is a good idea to carry this form with you. Temporary Life Insurance Agreement (TIA) Limits
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TIA is not available on TRIAL applications. TIA is only available if the Proposed Life Insured is at least 15 days old and not older than 65 years as of last birthday. Collecting the Initial Premium
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Money can only be collected at the time of application completion or upon delivery of the policy. The application, TIA receipt and Illustrations and Investment Allocation Forms
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If the plan is universal life, a signed illustration and an investment allocation form should accompany the application. Application for Life Insurance
to RBC Life Insurance Company
Proposed Life Insured (If joint application, complete separate application for each life)
Number of Years at this Occupation Former Occupation (if at current occupation less than 2 years) Applicant/Owner if other than the Proposed Life Insured
Mailing Address (for billings, notices, etc.) If Joint Owners, ownership is to be with right of survivorship unless otherwise indicated. Contingent Owner
If all Owners predecease the Life Insured(s), in the absence of a Contingent Owner, ownership passes to the estate of the last surviving Owner. 8. Language of Policy
Underwriting May 12, 2009 PPI Business Group (89248) Beneficiary
If the Beneficiary is a minor we strongly advise the appointment of a trustee. Complete the Appointment of Trustee form. Ensure total shares equal 100%. 10. Primary Beneficiary 11. Contingent Beneficiary – If all Beneficiaries predecease the Life Insured(s), the proceeds are payable to the Contingent Beneficiary if any, otherwise to the estate of the Owner. Insurance applied for
Are you applying for Income Replacement Benefits? Yes
If yes, please complete the Income Replacement Supplement. Are you applying for Deposit Completion Rider? Yes
If yes, please complete the Income Replacement Supplement. Are you applying for Critical Illness Benefits? Yes
If yes, please complete the Critical Illness Supplement. Are you applying for Long Term Care Benefits? Yes
If yes, please complete the Long Term Care Supplement. Are you applying for Buy/Sell Benefits? Yes
If yes, please complete the Buy/Sell Benefits Supplement. Existing Insurance
If yes, complete below. Complete Disclosure forms where necessary. Amount of Life Insurance including Other types of Insurance e.g. to replace any insurance now in force Accidental Death Benefit, CI, with any company? Underwriting May 12, 2009 PPI Business Group (89248) Premium Payment
If applying for Universal Life, a signed illustration and a completed Investment Allocation form must be submitted with the application. Is the monthly Temporary Insurance Agreement (TIA) premium to be withdrawn by PAD? Yes If the TIA has not been applied for, is the initial premium to be withdrawn by PAD? Pre-Authorized Debit (PAD) Agreement
Ensure you read and understand the section “Collection and Use of Personal Information”.
RBC Life Insurance Company (RBC Life) is authorized to make scheduled monthly withdrawals to pay the premium in accordance with the premium schedule set out in this policy/policies, including the initial premium and/or the Temporary Insurance Agreement premium, if requested in this Application, against the account at the financial institution below, or any other financial institution that the Payor(s) may later designate. RBC Life is not required to provide notification before the Temporary Insurance Agreement premium and/or the
initial premium is debited, or if the amount of withdrawal should vary.
unless otherwise indicated in the Special Requests section below, such withdrawals shall be dated on the day of the month on which the premium is due under the policy or, if more than one policy is included in this Agreement, the withdrawals shall be dated to coincide with the existing policy/policies. the financial institution indicated below is authorized now or at any subsequent time to honour any requests made by RBC Life to withdraw premium or fees from the account indicated below, which may include a redraw within 30 days should any withdrawal not clear the account, notification of any change to the account information provided below, shall be given to RBC Life by the Payor(s), at a minimum of 5 days prior to the next scheduled withdrawal. The Payor(s) agrees that from time to time they may authorize RBC Life to deduct such payments from another account upon the Payor’s oral or written instructions. this Agreement will terminate in respect of all policies included in it upon 10 days written notice by RBC Life or by the Payor(s). The Payor(s) may obtain further information on their right to cancel a PAD agreement by visiting the Canadian Payments Association website at www.cdnpay.ca. In the event that a PAD is disputed, the Payor(s) agrees to contact RBC Life. For recourse purposes, this PAD is considered a Personal PAD. The Payor(s) has certain recourse rights if any debits do not comply with this agreement. For example, the Payor(s) has the right to receive reimbursement for any PAD that is not authorized or is not consistent with this PAD Agreement. To obtain more information on recourse rights, the Payor(s) may contact their financial institution or visit www.cdnpay.ca. the names and signatures of all persons required to authorize withdrawals from the account indicated are included below. Add to existing PAD with policy number(s): Special Requests (withdrawals are limited between the 1st – 28th of the month) Underwriting May 12, 2009 PPI Business Group (89248) Pre-Authorized Debit (PAD) Agreement continued
Bank Information
Please attach a sample cheque marked void (a line of credit account cannot be used).
Print Name of Second Payor (Account Holder) (if any) ATTACH A SAMPLE (VOID) CHEQUE HERE (if applicable)
Underwriting May 12, 2009 PPI Business Group (89248) Personal Information
(a) had any application for any form of life or health insurance, any change or reinstatement declined, rated, cancelled or modified in any way? If yes, please give details. (b) applied for or received a pension, including CPP disability, income replacement benefits, compensation, workers compensation benefits of any type or Employment Insurance Disability Benefits? If yes, please give details. (c) in the last 3 years engaged in any activity or sport, including but not limited to racing, sky diving, ultra-light flying, hang gliding, scuba diving, mountaineering, heli-skiing, CAT or back-country skiing or have plans to do so? If yes, please provide details or complete the appropriate questionnaire. (d) flown an aircraft as pilot or student pilot or operated as a crew member in the last 3 years or have plans to do so? If yes, please complete the Aviation Questionnaire. (e) within the last 2 years travelled outside Canada or the United States of America or have plans to do so in the future? If yes, please complete the Foreign Travel Questionnaire. (f) been found guilty of a driving violation, had a driver’s licence revoked or suspended in the last 10 years or are any such charges pending? If yes, please give details. (g) been found guilty of driving while impaired or any other alcohol or drug related offence within the last 10 years or are any such charges pending? If yes, please explain fully. (h) been found guilty of a criminal offence within the last 10 years or are there any criminal charges pending? If yes, (i) or the Applicant/Owner declared bankruptcy within the last 10 years? If yes, please explain fully, including date (j) ever had a licence to practise any occupation suspended, revoked or under review; been found guilty of any professional misconduct or had disciplinary measures recommended in connection with any licence to practise? If yes, please explain fully. Additional details of “yes” answers. Underwriting May 12, 2009 PPI Business Group (89248) Tobacco Usage
The information listed below is relied upon to establish the policy’s premium rate and is material to the insurance risk. Failure to make proper disclosure will entitle RBC Insurance to render the policy null and void. 20. Has the Proposed Life Insured ever used any of the following: Quantity/Frequency Date last used
(h) smoking cessation products such as Zyban, patches or (i) tobacco substitutes such as betel nuts, betel leaves, Additional details of “yes” answers. Underwriting May 12, 2009 PPI Business Group (89248) Financial Information – Proposed Life Insured
Complete for all applications
What is your annual earned income in Canadian dollars from: What is your annual income in Canadian dollars from other sources: 5. If you are not currently working, what is the source of your income? 6. What is your estimated net worth in Canadian dollars? 7. What is the amount of mortgage outstanding on your personal residence? Complete if applying for business insurance
Book value of business in Canadian dollars $ Fair market value of business in Canadian dollars $ Net annual before tax income of business in Canadian dollars $ Are other partners, owners, executives insured for a similar amount? Yes Complete if Proposed Life Insured is under age 16
Are all other children in the family insured? Yes Source of premium. If not from parents, please provide details. Underwriting May 12, 2009 PPI Business Group (89248) Medical History of Proposed Life Insured
2. Has your weight changed in the last year? Yes 3. (a) Name and address of your personal health care professional/clinic (If none, so state) (b) How long have you been a patient there? (d) What was the diagnosis, treatment given or medication prescribed? (If none, so state) 4. (a) Other than the above, within the past year have you consulted any other health care professional? Yes (b) If yes, give the date, the reason and any treatment given or medication prescribed. 5. Any family history of diabetes mellitus, cancer (specify type), high blood pressure, colon polyps, heart disease, polycystic kidney disease or other kidney disease, stroke, Huntington Disease, hepatitis or Parkinson Disease? Yes Underwriting May 12, 2009 PPI Business Group (89248) Medical History continued
6. Have you ever had or been told you have or have you ever received treatment or advice for: (a) dizziness, fainting, convulsions, epilepsy, seizures, tremor, Parkinson disease, headache, migraine, speech problems, paralysis, stroke, transient ischemic attack (TIA), memory disorder, Alzheimer disease, numbness, neuropathy, multiple sclerosis or other neurological disorder? (b) anxiety, depression, chronic fatigue, suicidal thoughts or any other psychiatric, emotional, behavioural, mental or (c) disorder of the eyes, ears, nose, mouth or throat? (d) shortness of breath, wheezing, chronic cough, chronic bronchitis, chronic obstructive lung disease, emphysema, asthma, blood spitting, hoarseness, pleurisy, pneumonia, tuberculosis, sleep apnea or other respiratory or lung disorder? (e) high blood pressure, elevated cholesterol, abnormal ECG (electrocardiogram), chest pain, angina, heart attack, myocardial infarction, coronary artery disease, coronary angiogram, angioplasty, coronary artery surgery, palpitation, irregular heart rhythm, heart failure, ankle swelling, heart murmur, rheumatic fever, heart valve abnormality, blood clot, thrombophlebitis, pulmonary embolus or other disorder of the heart, blood vessels or circulatory system? (f) ulcer, stomach or intestinal bleeding, jaundice, hepatitis, hepatitis carrier state, colitis, Crohn disease, chronic diarrhea or other disorder of the stomach, intestines, liver, gallbladder or pancreas? (g) sugar, protein, blood or pus in the urine, kidney stone, kidney infection, kidney cysts, prostate disorder, abnormal PSA (Prostate Specific Antigen) test, ovarian, uterine or cervical disorder, sexually transmitted disease, complications of pregnancy, or any other disorder of the bladder, kidneys or reproductive tract? (h) AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS-Related Complex) or a positive test for antibodies to (i) skin cancer, dysplastic nevi, rheumatism, arthritis, gout, lupus, SLE (Systemic Lupus Erythematosus), osteoporosis, amputation, fibromyalgia, chronic pain disorder or any other disorder of the skin, joints, muscles, bones, ligaments, soft tissues, discs, neck, back or spine? (j) any cancer, tumour, cyst, mass, lesion, lump, nodule or breast disorder? (k) anemia, bleeding disorder, clotting disorder, allergies, immune disorders, lymphoma, leukemia, or any other disorder of the blood or lymph nodes or any serious or unexplained infection? (l) diabetes mellitus, thyroid or other endocrine or hormonal disorder? Details of “Yes” answers. Include date, diagnoses, results of tests, duration and names and addresses of all attending health care professionals and medical facilities. Underwriting May 12, 2009 PPI Business Group (89248) Medical History continued
7. (a) Do you currently take any medications, including herbal, naturopathic, homeopathic or other remedies? (b) Within the past 12 months have you received chiropractic or acupuncture treatment? (c) In the past 5 years have you had any other tests not mentioned above (such as Coronary Calcium Score, CT scan, (d) Have you been advised to undergo investigations, have treatment, testing or consultation which has not yet been (e) Are you aware of any other symptom or health-related disorder for which you have not yet consulted a health care (f) Have you ever received, or been advised to seek counselling or treatment regarding the use of alcohol, or ever attended Alcoholics Anonymous (AA) meetings or any other similar organization? (g) Do you currently use alcoholic beverages? If yes, state type, amount and frequency. (h) Have you ever used sedatives, tranquilizers or hallucinogenic or narcotic drugs including cocaine and marijuana except as prescribed by a health care professional? (i) Females only: Are you currently pregnant? If yes, please state your expected delivery date Details of “Yes” answers. Include date, diagnoses, results of tests, duration and names and addresses of all attending health care professionals and medical facilities. Underwriting May 12, 2009 PPI Business Group (89248) Temporary Life Insurance Application
If any of the following questions are answered ‘Yes’ or if any Proposed Life Insured is under 15 days or over 65 years old, do not proceed. Has any Proposed Life Insured: 1. ever been treated for or had any indication of heart or blood vessel disease, high blood pressure, chest pain, stroke, transient ischemic attacks (TIA), diabetes mellitus, chronic kidney, liver or lung disease, cancer or tumours, multiple sclerosis, paralysis, Alzheimer or Parkinson disease, AIDS or HIV infection, loss of speech, blindness or deafness? 2. within the last year, other than normal childbirth, been admitted to hospital or other medical facility or been advised to do 3. been advised to have any tests, investigations or surgery not yet done? 4. in the last year had any application for life insurance, change or reinstatement declined, rated or modified in any way? I declare that the above questions have been truthfully answered. Signature of Joint Applicant/Owner (if any) Signature of any minor Proposed Life Insured age 16 and over or parent/guardian of minor Proposed Life Insured under age 16 Notice regarding the MIB, Inc.
Information regarding your insurability will be treated as confidential. RBC Life Insurance Company or its reinsurers may, however, make a brief report to the MIB, Inc., a non-profit membership organization of life insurance companies, which operates an information exchange on behalf of its members. If you apply to another MIB member company for life or health insurance coverage or a claim for benefits is submitted to such company, MIB, upon request, will supply such company with the information in its file. Upon receipt of a request from you, MIB will arrange disclosure of any information it may have in your file. If you question the accuracy of the information in MIB’s file, you may contact MIB and seek a correction. The address of MIB’s information office is: MIB, Inc., 330 University Avenue, Toronto, Ontario, CANADA M5G 1R7 Telephone: (416) 597 - 0590. Web site: http://www.mib.com RBC Life Insurance Company or its reinsurers may also release information in its file to other life insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted. Underwriting May 12, 2009 PPI Business Group (89248) Temporary Life Insurance Receipt
RBC Life Insurance Company (RBC Life) acknowledges receipt of $ payment of one monthly premium (1/12 of an annual premium if paying annually) at standard rates for the life insurance policy applied for under this Temporary Life Insurance Agreement (Agreement) or authorization has been provided to RBC Life in this Life Insurance Application (Application) to withdraw this sum immediately by pre-authorized cheque in payment for coverage under this Agreement on the life of: The Temporary Life Insurance Application, the Application and the payment by cheque (if applicable) must all be dated the same date or the Agreement is null and void. Temporary Life Insurance Agreement
RBC Life Insurance Company (RBC Life) agrees to insure the Proposed Insured(s) specified on the Temporary Life Insurance Receipt, who, in this Agreement, will be referred to as the Proposed Insured, subject to the terms and conditions set out below. Coverage
Temporary life insurance commences once the Application and Temporary Life Insurance Application have been signed and the payment for coverage under this Agreement has been received. In the event of the death of the Proposed Insured(s) (if more than one Proposed Insured, the first or last-to-die according to the Application) while this Agreement is in force and subject to a maximum aggregate liability of $1,000,000 under this and all other Temporary Life Insurance Agreements issued by RBC Life on the Proposed Insured(s), RBC Life will pay to the beneficiary(s) designated in the Application, the LESSER OF: (a) the amount of life insurance applied for in the Application, OR If the total amount of life insurance applied for on the Proposed Insured(s) in the Application is greater than the maximum payable under this Agreement and the Proposed Insured(s) die/dies while covered under this Agreement, RBC Life will refund the portion of any payment for coverage over the maximum payable under this Agreement for that Proposed Insured. Termination of Temporary Life Insurance
Insurance coverage provided by this Agreement will terminate on the earliest of: (a) 90 days from the date the Application is signed, OR (b) the date on which RBC Life mails notice of termination of insurance under this Agreement, OR (c) the date the policy RBC Life issues in response to the Application takes effect, OR (d) the date the Proposed Owner(s) refuse(s) to accept delivery or otherwise rejects the policy issued in response to the Application, (e) the date the Proposed Owner(s) ask(s) RBC Life to cancel this Agreement or otherwise withdraws the Application, OR (f) the date of death of the Proposed Insured (if more than one Proposed Insured, the date of death of the first or last-to-die according Except in the case of fraud, payment received by RBC Life will be refunded in the event of termination under (a), (b), (d) or (e). Limitations and Exclusions
(a) If there is material misrepresentation or non-disclosure in any part of the Application or Temporary Life Insurance Application, any application supplement or questionnaire, no Temporary Life Insurance will take effect and RBC Life shall, except in the case of fraud, refund the payment for this Agreement. RBC Life shall have no liability if the specified Proposed Insured(s), while sane or insane, commit(s) suicide, except RBC Life shall (b) refund the payment for this Agreement. (c) No accidental death benefit rider, disability/income replacement, critical illness, children’s term rider, or return/waiver of premium benefits are provided under this Agreement. (d) No Temporary Life Insurance will take effect if any question is answered “Yes” and/or not answered in the Temporary Life Insurance Application, and/or if the Application and/or the Application for Temporary Life Insurance Application is (are) not signed, or the Proposed Insured is under 15 days old or over 65 years of age, or the payment for coverage under this Agreement is not honoured on presentation and/or the date of the Application, the Temporary Life Insurance Application and the cheque (if applicable) are not dated on the same date. (e) Temporary Life Insurance is not available if the Application is made under any conversion provision of an existing policy or the conversion option of a rider to any existing policy. Underwriting May 12, 2009 PPI Business Group (89248) Authorization
I understand and authorize the Company (RBC Life Insurance Company and its reinsurers) to conduct such investigation as is necessary and to gather personal information concerning me. I understand that the Company will create and maintain files, which contain personal information concerning me. I also understand that access to personal information concerning me will be limited to the employees of, and other persons engaged by, the Company in performance of their duties, or the persons to whom I have granted access, in writing, or to any other person authorized by law. I further understand that, except when the Company can and does lawfully restrict my access to personal information concerning me, I will be permitted to review copies of documents containing said personal information in the possession of the Company, upon paying reasonable copying charges. I further understand that I will be permitted to request access to such documentation and to have any errors in the personal information noted and corrected by formulating a written request to the Company mailed to the employee who is handling my Application. I authorize and direct the persons, institutions and organizations listed below to disclose and provide to the Company any information, records or other data regarding me, my medical history or treatment, or my past and present income or employment that is relevant to this Application, which they have in their possession or control. Persons to whom this Authorization applies: Any licensed physician, nurse, counselor, psychologist, social worker, therapist, pharmacist, physiotherapist, chiropractor, or other rehabilitation professional or other health care practitioner; and also any hospital, clinic, pharmacy, or other medical facility or provider of health care or treatment; and also the provincial health insurance plan, any insurance or reinsurance company or other financial institution; and also my employer or former employers; and also any federal or provincial government department or organization, including the federal or provincial income tax authorities and provincial motor vehicle divisions; and also the MIB, Inc.; and also to any other person, agency, credit bureau or institution having information, records or data regarding me. I understand that any information, records or data received by the Company pursuant to this authorization, both medical and non-medical, will be used for the assessment of insurance risk for underwriting purposes and for the purpose of evaluating any claim for benefits or to assess the validity of the policy as issued. I also understand that underwriters employed by PPI Financial Group may discuss the underwriting of this application with the Company, and, in the event a policy(ies) is issued, PPI Financial Group may be provided with information related to the administration of the policy(ies) and to facilitate services I have requested. To the extent reasonably necessary for those purposes, I authorize the Company to disclose any of the said information, records or data received: to the MIB, Inc., and to other insurance companies or any reinsurer and to the underwriters and other necessary employees of PPI Financial Group. I also authorize the Company to release to my health care professional any medical information obtained for this insurance application including the results of any blood or urine test or urine drug screening tests for purposes of revealing findings which might require further investigation or treatment or for purposes of explaining any underwriting decision. This authorization is valid until revoked by me in writing. A photocopy of this authorization, as executed by me, will be as valid as the original. Signature of any minor Proposed Life Insured age 16 and over or parent/guardian of minor Proposed Life Insured under age 16 Underwriting May 12, 2009 PPI Business Group (89248) Authorization
I understand and authorize the Company (RBC Life Insurance Company and its reinsurers) to conduct such investigation as is necessary and to gather personal information concerning me. I understand that the Company will create and maintain files, which contain personal information concerning me. I also understand that access to personal information concerning me will be limited to the employees of, and other persons engaged by, the Company in performance of their duties, or the persons to whom I have granted access, in writing, or to any other person authorized by law. I further understand that, except when the Company can and does lawfully restrict my access to personal information concerning me, I will be permitted to review copies of documents containing said personal information in the possession of the Company, upon paying reasonable copying charges. I further understand that I will be permitted to request access to such documentation and to have any errors in the personal information noted and corrected by formulating a written request to the Company mailed to the employee who is handling my Application. I authorize and direct the persons, institutions and organizations listed below to disclose and provide to the Company any information, records or other data regarding me, my medical history or treatment, or my past and present income or employment that is relevant to this Application, which they have in their possession or control. Persons to whom this Authorization applies: Any licensed physician, nurse, counselor, psychologist, social worker, therapist, pharmacist, physiotherapist, chiropractor, or other rehabilitation professional or other health care practitioner; and also any hospital, clinic, pharmacy, or other medical facility or provider of health care or treatment; and also the provincial health insurance plan, any insurance or reinsurance company or other financial institution; and also my employer or former employers; and also any federal or provincial government department or organization, including the federal or provincial income tax authorities and provincial motor vehicle divisions; and also the MIB, Inc.; and also to any other person, agency, credit bureau or institution having information, records or data regarding me. I understand that any information, records or data received by the Company pursuant to this authorization, both medical and non-medical, will be used for the assessment of insurance risk for underwriting purposes and for the purpose of evaluating any claim for benefits or to assess the validity of the policy as issued. I also understand that underwriters employed by PPI Financial Group may discuss the underwriting of this application with the Company, and, in the event a policy(ies) is issued, PPI Financial Group may be provided with information related to the administration of the policy(ies) and to facilitate services I have requested. To the extent reasonably necessary for those purposes, I authorize the Company to disclose any of the said information, records or data received: to the MIB, Inc., and to other insurance companies or any reinsurer and to the underwriters and other necessary employees of PPI Financial Group. I also authorize the Company to release to my health care professional any medical information obtained for this insurance application including the results of any blood or urine test or urine drug screening tests for purposes of revealing findings which might require further investigation or treatment or for purposes of explaining any underwriting decision. This authorization is valid until revoked by me in writing. A photocopy of this authorization, as executed by me, will be as valid as the original. Signature of any minor Proposed Life Insured age 16 and over or parent/guardian of minor Proposed Life Insured under age 16 Underwriting May 12, 2009 PPI Business Group (89248) Declarations, Agreements and Consents
The Applicant/Owner and the Proposed Life Insured, if other than the Applicant/Owner, declare to the best of their knowledge that all statements and answers in all parts of this application and in any supplement to this application are full, complete and true and agree that: 1. RBC Life Insurance Company (RBC Insurance) has 90 days to consider and act upon this application from the date the application was signed. If RBC Insurance has not given notice of approval or rejection within that time, this application shall be considered to have been declined, 2. insurance under the policy shall take effect only when (a) a policy tendered for delivery is accepted by the Applicant/Owner, (b) the full initial premium has been paid and (c) provided no change in insurability of any Proposed Life Insured has taken place between the time of application and delivery. If Medical History - Part 2, is submitted prior to completion of the application, the application shall be deemed to have been made as of the time such History was submitted, 3. RBC Insurance may be entitled to render this policy and any Temporary Life Insurance Agreement null and void if there is misrepresentation or non-disclosure in any part of the application for insurance, medical examination or any questionnaire completed in connection with this application that is material to the insurance risk, 4. the entire contract of insurance shall be the policy, any attached endorsements, exclusions, amendments or documents and all completed parts of this application, application supplement or questionnaire. Acceptance of the policy will constitute agreement to its terms and notification of any changes specified by RBC Insurance in the policy, 5. no statement made to and no information acquired by a representative of RBC Insurance or an examining physician shall be attributed to or binding upon RBC Insurance unless contained in the application or any related declaration of health-related evidence of insurability. No one other than an officer of RBC Insurance may (a) alter or modify the terms of this application or policy or (b) waive any of RBC Insurance’s rights or requirements, 6. I have read the section entitled “Collection and Use of Personal Information” appearing in this application and understand and 7. a copy of the “Notice regarding the MIB, Inc.,” has been received and read, 8. unless otherwise requested in the Language of Policy question in this application, the policy and all related documents have been expressly requested to be in the English language. À moins de stipulation contraire à la question relative à la langue du contrat de la présente proposition, il a été expressément demandé que le contrat et tous les documents qui s’y rapportent soient rédigés en anglais. Signature of any minor Proposed Life Insured over age 16 Signature of Applicant/Owner if other than Proposed Life Insured (if Corporate Owner, include Title of signing officer; if Trustee Owner, sign as Trustee and identify the Trust) Signature of Joint Applicant/Owner (if any) Underwriting May 12, 2009 PPI Business Group (89248) Representative’s Report
1. How long have you known the Proposed Life Insured? 3. (a) Is the Proposed Life Insured fluent in the English language? Yes (b) If the Proposed Life Insured is not fluent in English, a Statement of Understanding in the Proposed Life Insured’s language of choice must be completed and submitted before underwriting can proceed. (c) If the language used to complete the application was not English, what was the language used and who explained the 4. (a) Were you present at the time of completion of the application? (b) Who was present at the time of completion of the application? Complete if Joint Lives
Complete if Proposed Life Insured is a Child Under 16 Years
(b) Are all other children in the family insured? Yes (c) Indicate the amount of insurance on: Father (d) Is the Owner the child’s parent? Yes 9. Complete to indicate if the application qualifies for the reduced premium load. Any one policy or multiple common client policies can be considered in order to meet qualification criteria for the reduced premium I acknowledge this application is being submitted as qualifying for the reduced premium load and the qualification criteria for the reduced premium load has been met using a) or any one or combination of b) to f): (a) Considering the merits of a single policy; (b) Combining multiple policies with a common insured; (c) Combining multiple policies with a common policy owner; (d) Combining multiple policies with a common corporate client; (e) Combining multiple policies with a common family member; (f) A pre-existing Security Fund* policy that has already been issued on the Reduced Premium Load basis on the same client or a client with a common relationship. This application does not qualify and is not being submitted on the reduced premium load basis. (Associates with questions about whether or not a particular scenario can qualify for the reduced premium load should contact their Underwriting May 12, 2009 PPI Business Group (89248) * The Security Fund name is the property of a third party. Representative’s Report continued
10. Representative’s Declaration
I have clearly explained the provisions and limitations of the policy being applied for (and the Temporary Life Insurance Agreement, if applicable) to the Proposed Life Insured(s) (and the Applicant/Owner, if applicable), all of the questions in the application were clearly asked of, or read by, the Proposed Life Insured(s) (and the Applicant/Owner, to the best of my knowledge, all of the answers and statements on the application have been fully and accurately recorded, I am not aware of any pertinent information about the Proposed Life Insured(s) that has not been disclosed on the application, if a policy is issued, I will deliver it to the Applicant/Owner only after obtaining confirmation that all conditions for delivery have been completely satisfied and there has been no change in the insurability of the Proposed Life Insured(s), I understand that I cannot modify the application, the Temporary Life Insurance Agreement or the terms of the policy, if issued.
I have complied with my duties and obligations in regard to Advisor Disclosure including providing an Advisor Disclosure Statement in writing to the Proposed Owner. Representative’s Supplementary Report
Please use this space for any special instructions or additional information which would be helpful in the underwriting of this risk. e.g. occupation, aviation, avocation, purpose of insurance, amount, income, health problems, habits, finances, replacement, insurable interest. Underwriting May 12, 2009 PPI Business Group (89248)

Source: http://www.hatton.ca/RBC%20Life%20App.pdf