Application for Whole Life Insurance
Underwritten by Western Life Assurance
Mail Application to: Everest Team,
5150 Spectrum Way, Suite 500, Mississauga, ON L4W 5G2
1 800 913 8318
ENSURE THE APPLICANT INITIALS ALL CHANGES. NO CORRECTION FLUID SHOULD BE USED.
SIMPLIFIED ISSUE APPLICATION FORM
1. Your Health
Insurance is a contract based on trust. Failure to disclose facts, material to this application, could make your contract void.
1.
Within the past THREE (3) years, have you been told you had, been diagnosed with, or received treatment for:
stroke; heart disease or disorder (such as heart attack, angina, severe/persistent chest pains or congestive heart failure); cancer; leukemia;
emphysema; kidney failure; diabetes requiring daily insulin; cirrhosis of the liver or chronic hepatitis; immune system disorder, or tested
positive for the human immune deficiency virus (HIV), or been diagnosed as having AIDS related complex (ARC), or AIDS; mental or
nervous system disorder, including Alzheimer’s, Parkinson’s, multiple sclerosis, cerebral palsy or suicide attempts?
 Yes  No
2.
Within the past THREE (3) YEARS, have you received treatment for alcohol or drug abuse or been advised by a physician to reduce
alcohol consumption due to alcohol abuse?
 Yes  No
3.
Within the past THREE (3) YEARS, have you had any life insurance application denied?
 Yes  No
4.
Within the past THREE (3) YEARS: If employed have you been unable to work for four (4) or more consecutive weeks due to illness or an
accident? If not employed have you been a patient in a hospital/extended healthcare/nursing home facility for four (4) weeks or longer?
 Yes  No
For individuals age 18-80 inclusive who answered “No” to all of the health questions, please proceed.
2. Select Your Coverage
 $5,000  $10,000  $15,000  $20,000  $25,000  $30,000
3. About You Date of Birth: ______________________________________________ Gender:  Male  Female
Month
Day
Year
Full Legal Name: ______________________________________________________________________________________________________
First Name
Middle Name
Last Name
_______________________________________________________________________________________________________________________
Mailing Address
City
Province
Postal Code
_______________________________________________________________________________________________________________________
Home Phone Number (Including Area Code)
4. I confirm that I can read and speak English:
 Yes  No. If No, please complete and attach the Interpreter’s Statement.
Form #WLA 00050 12-2014
5. Your Beneficiary (Required)
____________________________________________________________________________________ __________________________________
First Name
Middle Name
Last Name
Relationship to You
____________________________________________________________________________________ __________________________________
First Name
Middle Name
Last Name
Relationship to You
____________________________________________________________________________________ __________________________________
First Name
Middle Name
Last Name
Relationship to You
6. Payment Type (Select only one):
 Monthly Payments
Note: If more than one
beneficiary is designated,
the beneficiaries will share
equally in the life insurance
benefit, unless otherwise
specified.
If a minor is named as
beneficiary
without
an
appointed trustee, a public
trustee may be required to
receive the proceeds. Fund
payment may be delayed or
paid to the courts.
 Single Payment (Client identification form required) Only available on $5,000 and $10,000 coverage amounts.
Signature of Cardholder or Cheque Account Holder - (Required if other than Applicant) ___________________________________________________
Payment Options (Select only one):
 Pre-Authorized Chequing - Attach a cheque marked “VOID” (only VOID cheques accepted)
 Credit Card  Visa  MasterCard
(We do not accept Visa Debit or Visa Prepaid Cards)
Card Number: ______________________________________________________ Expiry Date (MM/YY): ________________________________________
Cardholder’s Name (Exactly as it appears on the card) ____________________________________________________________________________________
__________________________________________________________________________________________________________________________
Mailing Address (Required if other than applicant)
City
Province
Postal Code
Payment Amount and Date
I understand that the effective date of this insurance policy will be on the date I enter below, provided that my first month’s premium has been
paid.
** You may not select a payment date that is more than 30 days from the date of your signature on the next page.
I authorize monthly payments in the amount of $________ for premium to be debited to the account or charged to the credit card.
I request that payments begin on ______________ and continue on approximately the same day of each month thereafter.
Month / Day **
I understand that the initial payment may be debited after this date due to time required for administrative processing, and in the event that
occurs, monthly payments thereafter will be on or near the day of the month I have selected.
This plan is only available to residents of Canada excluding Quebec.
Form #WLA 00049 05-2016 BW
Declaration and Authorization
1.
2.
3.
4.
5.
I declare that I am legally authorized to reside in Canada and reside within
the country at least 6 months a year.
I declare that all information and statements in this Simplifed Issue
Application Form and any questionnaire or declaration of insurability made
in connection with this application are, to the best of my knowledge and
belief, true, accurate and complete.
• I may revoke my authorization at any time, subject to providing
30 days notice. To obtain a sample cancellation form, or for more
information on my right to cancel a PAP Agreement, I may contact
my financial institution or visit www.cdnpay.ca
• Every effort will be taken to meet the same date every month,
however this date could change for a given month.
I understand and agree that Western Life Assurance is relying on the
information and statements provided to consider my application for
insurance and to determine whether to issue a policy and that in the event
of false or misleading information or statements, any issued policy shall be
NULL and VOID. Should my health change at any time between the date
of this application and the effective date of my insurance I must contact
Western Life Assurance who will determine whether I am still eligible for
coverage and a failure to do so may result in any issued policy being NULL
and VOID.
I declare and understand that this application by me is not intended to
replace or change any existing life insurance or annuity policy.
• Western Life Assurance is not required to provide notification before
the initial premium is debited.
• I have certain recourse rights if any debit does not comply with this
agreement. For example, I have the right to receive reimbursement
for any debit that is not authorized or is not consistent with this preauthorized payment (PAP) Agreement. To obtain more information
on my recourse rights, I may contact my financial institution or visit
www.cdnpay.ca
I understand that if I die from self-inflicted injuries, while sane or insane,
within two (2) years from the effective date or date of the most recent
reinstatement, the amount of insurance will be limited to all premiums paid
since such date.
b.
c.
The information collected on this application for insurance is required
for the purposes of considering and if approved, processing my
application for insurance and to administer any insurance, the Everest
funeral planning and family support assistance benefit and to investigate
claims. This information and information in my customer file, may be
used by and exchanged among Western Life Assurance, its agents,
Everest, reinsurers and authorized administrators for these purposes or
as other-wise authorized or required by law. This information may be
processed and stored in the United States and may be accessible to the
United States government, courts or law enforcement or regulatory
agencies through the laws of the United States. From time to time
Western Life Assurance or Everest, or either of their approved partners
may also use this information to offer me additional products and
services but my consent to the use of my information for this additional
purpose is optional. If I wish more information about Western Life’s
personal information handling practices I may write to
Western Life Assurance at P.O. Box 3300, Winnipeg MB R3C 5S2,
e-mail [email protected] or call 1-888-647-5433.
For purposes of processing my application for insurance and
administering claims, I hereby authorize any physician, practitioner,
health care provider, hospital, health care institution, medical
organization, clinic and any other medical or medically related facility,
government office or provincial health insurance plan, insurance
company, workers’ compensation board or similar plan or organization,
to release and exchange with Western Life Assurance, personal health
information. This authorization shall take effect on the date it is signed
and it shall expire seven years after the termination of any policy issued
as a result of this application. I understand that I may revoke this
consent at any time but if I do, Western Life Assurance may be unable
to process my application for insurance or administer the insurance or
claims related to a policy, if issued.
I understand that if I die within these first two years, defined as the
“contestability period”, Western will investigate the details of my medical
history to confirm that I accurately answered all health questions on this
application. Western also reserves the right to request medical information
after the two year period if for any reason they believe I may have failed to
fully disclose my medical history.
6. I understand that coverage begins only after approval of my application by
Western Life Assurance and then only if the first premium is paid in full and
honoured by the Financial Institution.
7.Authorization
I understand that premiums are a level amount as stated in my policy
contract. I also understand that in certain instances, such as a returned
cheque or missed premium, that the premium can be increased to cover the
fees and missed past premiums.
In the event of an unsuccessful payment, a $35.00 fee will apply.
I agree that this authorization in no way affects the terms or conditions of
the policy.
This authorization shall continue in force so long as said policy shall qualify
for premium payments under this plan or until this authorization is revoked.
Either party to this agreement may terminate this authorization by written
notice mailed to the other party at his address of record.
a.
If the Credit Card Payment Plan has been selected...
Western Life Assurance is requested and authorized to charge my
Credit Card. I agree to furnish Western Life Assurance with the updated
Credit Card Expiry date as required. This authorization extends to any
replacement cards I may receive and will remain in effect until I cancel it.
Personal Information Notice and Authorization:
If the Pre-Authorized Payment Plan has been selected...
Western Life Assurance is requested and authorized to draw cheques under
its Pre-Authorized Payment Plan on the Account and Financial Institution
designated by me. I further authorize such institution and any of its
branches to deal with such transfers as though they were signed by me.
• I also agree to furnish Western Life Assurance with a voided blank
cheque now and at any future time, as required, to assure the accurate
imprinting of bank information on my Pre-Authorized transfers.
The present consent, declaration and authorization is valid for the purposes of the present contract, its modifications, extension or reinstatement. A photocopy of this
consent shall be as valid as the original.
By signing below, I confirm I am the applicant listed in the About You section of this form, that I am legally authorized to reside in Canada and reside within the
country at least six months a year. I further confirm that all information and statements in this application and any questionnaire or declaration of insurability made
in connection with this application are, to the best of my knowledge and belief, true, accurate and complete. I further confirm I understand that I am purchasing a
whole life insurance policy and that the proceeds of a claim on this policy can be used at the discretion of my beneficiary and/or estate and I understand that the Everest Concierge Service is included as a benefit of the whole life insurance policy I am purchasing.
Signed at ___________________________________, _________________________ this _____________day of _____________________, __________
(City)
(Province)
(Month)
(Year)
_____________________________________________________________________________________________________________________________
Applicant’s Signature
AGENT’S INFORMATION
Agent’s First Name
A
G
E
N
T
1
City
Your SMD’s Name
Agent’s Code
Agent’s Last Name
Province
A
G
E
N
T
2
Agent’s First Name
Agent’s Last Name
City
Province
Your SMD’s Name
Agent’s Code
Page 2 - Simplified Issue Application Form
PREMIUM RATES FOR WESTERN LIFE SIMPLIFIED ISSUE WHOLE LIFE INSURANCE
Version 05-2016
Mo nthly Payments ( $)
MALE
5,000
10,000
15,000
20,000
25,000
30,000
5,000
10,000
15,000
20,000
25,000
30,000
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
20
21
21
21
21
22
22
22
23
23
23
24
25
25
25
26
26
26
26
27
27
27
27
28
28
29
29
29
30
30
31
31
31
32
33
33
34
34
35
36
37
37
38
39
40
41
43
44
45
46
48
49
50
53
55
58
60
62
66
70
74
77
81
30
30
30
30
31
31
32
32
32
33
33
33
34
34
35
35
35
36
36
37
37
38
38
39
39
40
41
42
42
43
44
44
45
46
47
48
49
50
52
53
55
56
58
60
62
64
65
67
71
74
77
81
84
90
95
100
106
111
119
126
134
142
149
33
33
34
34
34
36
36
36
37
37
38
39
39
40
40
41
42
42
43
43
44
45
45
46
46
48
49
49
50
52
52
54
55
56
58
59
61
62
64
66
68
70
73
76
78
80
83
86
90
94
98
102
107
114
120
126
133
140
150
160
170
179
188
40
40
41
41
41
44
44
44
45
45
47
48
48
49
49
51
52
52
53
53
55
56
56
57
57
60
61
61
62
65
65
68
69
70
73
74
77
78
81
83
86
89
93
97
100
102
106
110
115
120
125
130
137
146
153
160
169
178
190
203
216
227
238
47
47
48
48
48
52
52
52
53
53
56
57
57
58
58
61
62
62
63
63
66
67
67
68
68
72
73
73
74
78
78
82
83
84
88
89
93
94
98
100
104
108
113
118
122
124
129
134
140
146
152
158
167
178
186
194
205
216
230
246
262
275
288
54
54
55
55
55
60
60
60
61
61
65
66
66
67
67
71
72
72
73
73
77
78
78
79
79
84
85
85
86
91
91
96
97
98
103
104
109
110
115
117
122
127
133
139
144
146
152
158
165
172
179
186
197
210
219
228
241
254
270
289
308
323
338
22
22
22
22
23
23
23
24
24
24
25
25
25
26
26
26
27
27
27
28
28
28
29
29
30
30
31
31
32
32
33
34
34
35
36
36
37
38
39
40
40
41
42
44
45
46
47
48
50
52
53
55
56
59
62
64
67
70
73
77
81
85
89
31
32
32
32
33
33
34
34
34
35
35
36
36
37
37
38
38
39
40
40
41
41
42
43
44
45
45
46
47
48
49
50
51
52
53
55
56
57
59
61
63
65
66
69
71
73
75
78
81
85
89
93
97
103
108
114
120
126
134
142
150
158
166
36
36
36
37
37
38
38
39
40
40
41
41
42
43
43
44
46
46
47
47
49
49
50
51
52
53
55
56
58
59
60
61
63
64
67
68
70
71
74
77
79
82
85
88
91
94
97
100
105
110
115
120
125
132
140
147
155
163
172
181
192
202
212
44
44
44
45
45
46
46
48
49
49
50
50
52
53
53
54
57
57
58
58
61
61
62
63
65
66
69
70
73
74
76
77
80
81
85
86
89
90
94
98
101
105
109
113
117
121
125
129
135
142
148
155
161
170
180
189
199
209
220
231
245
258
271
52
52
52
53
53
54
54
57
58
58
59
59
62
63
63
64
68
68
69
69
73
73
74
75
78
79
83
84
88
89
92
93
97
98
103
104
108
109
114
119
123
128
133
138
143
148
153
158
165
174
181
190
197
208
220
231
243
255
268
281
298
314
330
60
60
60
61
61
62
62
66
67
67
68
68
72
73
73
74
79
79
80
80
85
85
86
87
91
92
97
98
103
104
108
109
114
115
121
122
127
128
134
140
145
151
157
163
169
175
181
187
195
206
214
225
233
246
260
273
287
301
316
331
351
370
389
* Age means age on the date coverage begins. Rates subject to change prior to purchase.
FEMALE
AGE*
PREMIUM RATES FOR WESTERN LIFE SIMPLIFIED ISSUE WHOLE LIFE INSURANCE
Version 05-2016
S ingle Payments ( $)
* Age means age on the date coverage begins. Rates subject to change prior to purchase.
FEMALE
MALE
AGE*
5,000
10,000
5,000
10,000
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
3,181
3,203
3,233
3,283
3,334
3,377
3,427
3,477
3,541
3,611
3,675
3,745
3,608
3,634
3,660
3,687
3,713
3,739
3,765
3,792
3,818
3,845
3,871
3,910
3,948
3,987
4,025
4,063
4,102
4,141
4,179
4,218
4,256
4,299
4,341
4,384
4,426
4,468
4,523
4,578
4,633
4,688
4,743
4,813
4,882
4,952
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
4,480
4,521
4,566
4,630
4,694
4,733
4,797
4,861
4,941
5,017
5,098
5,189
5,269
5,312
5,370
5,412
5,470
5,528
5,571
5,629
5,673
5,731
5,774
5,832
5,890
5,962
6,020
6,079
6,137
6,196
6,256
6,315
6,375
6,483
6,591
6,713
6,821
6,930
7,030
7,130
7,230
7,317
7,416
7,573
7,717
7,873
8,018
8,174
8,387
8,596
8,799
9,009
9,204
9,430
9,703
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
3,337
3,358
3,395
3,446
3,497
3,555
3,606
3,657
3,721
3,792
3,855
3,926
3,780
3,816
3,851
3,886
3,922
3,957
3,992
4,028
4,063
4,098
4,134
4,176
4,218
4,260
4,302
4,344
4,386
4,428
4,470
4,513
4,555
4,605
4,655
4,705
4,755
4,805
4,856
4,907
4,958
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
4,701
4,742
4,796
4,857
4,917
4,988
5,048
5,109
5,186
5,274
5,351
5,439
5,516
5,581
5,646
5,712
5,777
5,843
5,908
5,974
6,040
6,106
6,172
6,235
6,299
6,364
6,429
6,494
6,559
6,625
6,691
6,758
6,825
6,950
7,075
7,200
7,325
7,450
7,544
7,638
7,732
7,825
7,917
8,065
8,212
8,359
8,505
8,652
8,865
9,072
9,274
9,472
9,665
9,826
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
www.everestfuneral.ca
THE EVEREST PACKAGE
EXCLUSIVELY OFFERED
THROUGH WFG
Who do you know that could benefit from Everest?
CLIENT’S NAME_______________________________DATE OF REFERRAL__________________
REFERRALS
1
First and Last Name
Telephone
Address
2
Relationship to your Client
Email Address
First and Last Name
Telephone
Address
3
Relationship to your Client
Email Address
First and Last Name
Telephone
Address
4
Relationship to your Client
Email Address
First and Last Name
Telephone
Address
Relationship to your Client
Email Address