Montréal QC H5B 1E2 (life and critical illness insurance ... · Page 3 of 10 B - Evidence of insurability B1 - Mandatory questions Has the proposed insured: Insured 1 Insured 2 1-ever

07177A (2020-05)

1, Complexe Desjardins Montréal QC H5B 1E2

200, rue des Commandeurs Lévis QC G6V 6R2

Reinstatement Application Request(life and critical illness insurance)

Page 1 of 10

Contract Number:

Important information

1. Usethisformtoapplyforlifeorcriticalillnessinsurancereinstatement.Iftherearemorethan2proposedinsureds,pleasefilloutanadditionalform.

2. If you also want to change policyowners, please complete the Request for Change of Policyowner (09614A). Please include a cheque or Pre-Authorized Debit Agreement (09312E) form (Quebec only) for premiums with your reinstatement application request.

3. Section F - Notice applicable to MIB, Inc. and section G - Personal Information Management (page 7) must be given to the policyowner.

Reinstatement rules:

If the contract was terminated less than 2 years ago and this termination was due to lapse, the contract can be reinstated as of the date of written acceptance by Desjardins Insurance, subject to receiving:

a) payment of all premiums owing; and b) evidence stating that each proposed insured meets Desjardins Insurance’s insurability standards.

Representative informationFirst and last names of representative(s)

(please print)Representative

code Fieldofficecode % share Email

A - General information

A1 - Policyowner - Individual

Policyowner 1 Policyowner 2

First and last names First and last names

Address (No., street, apt.) Address (No., street, apt.)

City Province City Province

Postal code Date of birth (yyyy/mm/dd) Postal code Date of birth (yyyy/mm/dd)

Email Email

10-digit phone number 10-digit phone number

Res.: Cell.: Res.: Cell.:

Bus.: Ext.: Bus.: Ext.:

A2 - Policyowner - Corporation, trust or other entity (e.g., Health Priorities - Business)

Note: Pleasefilloutform08295E for any life insurance contract with cash surrender values or a savings component.

Federal business number Provincial business number Federal trust number Provincial trust number(all provinces and territories) (Quebec only) ou (all provinces and territories) (Quebec only)

T - -Important: If the business or trust number is missing, the policyowner must provide it to Desjardins Insurance within 90 days.

Company name Contact person

Address - No., street, apt. City Province Postal code

Email address 10-digit phone number

, Ext.:

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A - General information (cont.)

A3 - Proposed insureds

Name of the proposed insured(s) Current occupation and annual income Date of birth (yyyy/mm/dd)

Current height and weight

1 $

2 $

A4 - Declaration of tax residence

• The declaration of tax residence must be completed by all policyownersidentifiedinsection A1 when requesting the reinstatement of a life insurance contract with cash surrender values or a savings component. For more details, please consult documentation on .

• Ifthepolicyownerisacorporation,trustorotherentity,pleasefilloutform08295E for the declaration of tax residence.

Policyowner 1 Policyowner 2

Please answer questions 1, 2 and 3, as applicable.

1- Are you a tax resident of Canada? Yes No

• If yes, give your social insurance number:

2- Are you a tax resident or a citizen of the United States? Yes No

• If yes,giveyourU.S.TaxpayerIdentificationNumber(TIN):

• If you do not have a TIN, have you applied for one? Yes No

3- Are you a tax resident in a country other than Canada or the United States? Yes No

• If yes,giveyourcountriesoftaxresidenceandtaxpayeridentification numbers in the table below.

• If you do not have a TIN, enter one of the following 3 reasons in the table below:

Reason A: I will apply or have applied for a TIN but have not yet received it.

Reason B: My country of tax residence does not issue TINs to its residents.

Reason C: Other reason.

Country of tax residence TIN

If you don’t have a TIN, choose reason A, B or C.

If “C”, please specify.

Important: If any information is missing on the policyowner’s declaration of tax residence, they must provide it to Desjardins Insurance within 90 days.

Please answer questions 1, 2 and 3, as applicable.

1- Are you a tax resident of Canada? Yes No

• If yes, give your social insurance number:

2- Are you a tax resident or a citizen of the United States? Yes No

• If yes,giveyourU.S.TaxpayerIdentificationNumber(TIN):

• If you do not have a TIN, have you applied for one? Yes No

3- Are you a tax resident in a country other than Canada or the United States? Yes No

• If yes,giveyourcountriesoftaxresidenceandtaxpayeridentification numbers in the table below.

• If you do not have a TIN, enter one of the following 3 reasons in the table below:

Reason A: I will apply or have applied for a TIN but have not yet received it.

Reason B: My country of tax residence does not issue TINs to its residents.

Reason C: Other reason.

Country of tax residence TIN

If you don’t have a TIN, choose reason A, B or C.

If “C”, please specify.

Important: If any information is missing on the policyowner’s declaration of tax residence, they must provide it to Desjardins Insurance within 90 days.

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B - Evidence of insurabilityB1 - Mandatory questions Has the proposed insured: Insured 1 Insured 21- ever submitted, to any insurance company, an application for life, disability, critical illness, or long term care insurance or for a contract reinstatement that was declined, deferred or approved with restrictions or an extra premium? If yes, please complete the table below, indicating the reason the application or reinstatement was declined or approved with restrictions or an extra premium.

Yes No Yes No

Name of company(ies) Date (yyyy/mm/dd) Reason

Insured 1

Insured 2

2- Family history: reported a history of cancer, heart disease, stroke, high cholesterol, high blood pressure, diabetes, kidney disorders, multiple sclerosis, Huntington’s chorea, colon polyps, motor neuron disorder, musculardystrophy,Parkinson’sdisease,Alzheimer’sdisease,cysticfibrosisoranyotherhereditarydisease in their family (father, mother, brothers, sisters)?

If yes, please complete the table below.

If applicable, indicate where any cancer is located in section B2 (page 5).

Yes No Yes No

Insured 1 Illness(es) Age at onset of illness Age if living Age at death Cause of death

Father

Mother

Brothers

Sisters

Insured 2 Illness(es) Age at onset of illness Age if living Age at death Cause of death

Father

Mother

Brothers

Sisters

3- used any form of tobacco or nicotine products (cigarette, cigarillo, cigar, pipe, electronic cigarette, vaping device, gum or patches) or anti-smoking medication in the past 12 months?

If yes, please complete the table below. Yes No Yes No

Daily use Type (if cigars, specify type)

Insured 1

Insured 2

4- smoked cigars or cigarillos on occasion?


Cigars Cigarillos

Monthly use Yearly use Monthly use Yearly use

Insured 1

Insured 2

5- quit smoking (meaning they are a former smoker)?


Quit smoking on (yyyy/mm/dd) Past daily use

Insured 1

Insured 2

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B - Evidence of insurability (cont.)

Has the proposed insured: Insured 1 Insured 2

6- declared bankruptcy within the past 5 years?


Date of bankruptcy (yyyy/mm/dd) Personal Business Date of discharge (yyyy/mm/dd)

Insured 1

Insured 2

7- a) participatedinactivitiessuchasflying,skydiving,scubadiving,mountaineering,climbing,off-trailskiing (including heli skiing), motor vehicle racing (including boat racing) or any other hazardous sports over the past 2 years?

If yes, please complete the appropriate questionnaire available on .

b) planned to participate in any hazardous sports over the next 12 months?

If yes, please complete the appropriate questionnaire available on .

Yes No

Yes No

Yes No

Yes No

8- beenfoundguiltyofdrivingundertheinfluenceofalcoholordrugswithinthepast5years? (Answer yes if they are currently facing charges for this type of offence or they are awaiting trial.)


Date of offence (yyyy/mm/dd) Type of offence Date of offence

(yyyy/mm/dd) Type of offence Driver’s licence reinstated (yyyy/mm)

Insured 1

Insured 2

9- beenfoundguiltyofanytrafficoffencesoradrivinginfractionthatledtothesuspensionorlossoftheir driver’s licence within the past 5 years?


Date of offence (yyyy/mm/dd) Type of offence Km

over limitDate of offence (yyyy/mm/dd)

Type of offence

Km over limit

Driver’s licence reinstated (yyyy/mm)

Insured 1

Insured 2

10- a) travelled or stayed outside Canada or the United States in the past 12 months?

b) Does the proposed insured intend to do so in the next 12 months?

If yes, please complete the table below or complete the Foreign Residence/Travel Questionnaire, available on .

Yes No

Yes No

Yes No

Yes No

Country City Departure date(yyyy-mm-dd)

Return date(yyyy-mm-dd) Purpose of trip

Insured 1

Insured 2

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B - Evidence of insurability (cont.)

Since the initial insurance application was signed, has the proposed insured: Insured 1 Insured 211- a) ever consumed alcoholic beverages? If yes, please complete the table below and specify their current weekly consumption and their consumption during the last 3 years, if different.

Yes No Yes No

Current weekly consumption Weekly consumption during the last 3 years

Insured 1

Insured 2

b) undergone or been advised to undergo treatment for alcoholism, been a member of a support group such as Alcoholics Anonymous, or been advised to reduce their alcohol consumption? If yes, please complete the Alcohol Consumption and/or Drug use Questionnaire, available on .

Yes No Yes No

12- ever used drugs or narcotics without a medical prescription? If yes, please complete the Alcohol Consumption and/or Drug use Questionnaire, available on . Yes No Yes No

13- ever been treated for drug use or been advised on this subject? If yes, please complete the Alcohol Consumption and/or Drug use Questionnaire, available on . Yes No Yes No

14- suffered illnesses or injuries of any kind? If yes, please provide relevant details in section B2. Yes No Yes No

15- consulted a physician or a healthcare professionnal, received treatment, been admitted to a healthcare facility or been advised to do so? If yes, please provide relevant details in section B2.

Yes No Yes No

16- undergone laboratory tests or exams for diagnostic purposes? If yes, please provide relevant details in section B2. Yes No Yes No

17- taken medication or followed a diet? If yes, please provide relevant details in section B2. Yes No Yes No

18- undergone or been advised to undergo laboratory tests to detect the AIDS virus, antibodies to the AIDS virus or a sexually transmitted disease? If yes, please provide relevant details in section B2.

Yes No Yes No

19- experienced discomfort, symptoms or signs for which they have not yet consulted a physician or other healthcare professional, or are waiting to consult one, or for which they have been advised to take medication or undergo surgery, tests or exams that have yet to be completed or for which they are currently awaiting results? If yes, please provide relevant details in section B2.

Yes No Yes No

B2 - Additional information for questions 2, 14, 15, 16, 17, 18 and 19, if applicable.

Insured 1 Insured 2 Date (yyyy/mm/dd)

Reason for consultation: illness, discomfort, symptom, sign, test or medication Name and address of physician or healthcare facility

C - Identification of the personal physicianIndicate the contact information of the personal physician who has the medical records of each proposed insured.

Proposed insured 1 Proposed insured 2 Same address as Proposed insured 1Name of personal physician Name of personal physician

Address (No., street, apt.) Address (No., street, apt.)

City City

Province Postal code Province Postal code

10-digit phone number Date of last visit (yyyy/mm/dd) 10-digit phone number Date of last visit (yyyy/mm/dd)

Reason for last visit and results Reason for last visit and results

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D - Authorization to collect and communicate personal informationForthesolepurposeofdeterminingmyinsurability,managingmyfileandprocessingclaims,IauthorizeDesjardinsInsuranceoritsreinsurers:1- tocollectfromanyindividual,legalentityorpublicorparapublicorganizationonlythepersonalinformationtheyhaveaboutmethatisneededtoprocessmyfile.This information may be collected from third parties, including any health care professional or establishment, MIB, Inc., insurance and reinsurance companies, personal informationbrokers,investigationfirms,thepolicyowner,myemployerormyformeremployers;2- todisclosetothoseindividuals,legalentitiesorpublicorparapublicorganizationsonlythepersonalinformationtheyhaveaboutmethatisneededtomanagemyfile;3- torequest,ifapplicable,aninvestigationreportaboutmeandtousethepersonalinformationcontainedinotherfilesitmayhavethatarenowclosed;4- todisclosetomypersonalphysiciananymedicalinformationaboutmethatwasobtainedduringtheevaluationofmyfile;5- to disclose to other insurers or reinsurers any information about me that is relevant to determining my eligibility for insurance;6- to provide a brief report of my personal information to MIB, Inc., including information on my health.This authorization also applies to collecting, using and disclosing personal information concerning my minor children, insofar as they are the subject to my application.A photocopy of this authorization is as valid as the original.Each policyowner and proposed insured, including children age 14 or older (Quebec) and 16 or older (provinces other than Quebec), have read this section before signing it.

XDate (yyyy/mm/dd)

X X XSignature of proposed insured 1 Signature of policyowner 1 Signature of guardian for children under age 18 (Quebec) and legal

representative for children under age 16 (provinces other than Quebec)

X X XSignature of proposed insured 2 Signature of policyowner 2 Signature of children age 14 or older (Quebec)

Signature of children age 16 or older (provinces other than Quebec)

E - Statements and signaturesThe policyowners and proposed insureds acknowledge that:1- The contract associated with this application will be reinstated on the date the application is approved by Desjardins Insurance, provided the following conditions are met: • all past due premiums are paid; and • there are no changes to the health or lifestyle habits of any of the proposed insureds between the date this application for reinstatement is signed and the date it is approved by Desjardins Insurance.2- In the event an insured person commits suicide, whether sane or insane, within 2 years of the reinstatement of the contract, Desjardins Insurance will not pay out any insurance amounts under the contract. Desjardins Insurance will only refund the premiums paid since the contract reinstatement date, without interest. The refund will be issued to the beneficiaryorbeneficiariesdesignatedintheoriginalinsuranceapplicationorinthemostrecentdocumentsignedbythepolicyownerforthatpurpose.3- Any misrepresentation made by the policyowners or proposed insureds, including a misrepresentation about smoking status, may render the contract void.The policyowners also acknowledge that:• the information provided on their ‘‘Declaration of tax residence’’ is correct and complete (if applicable). They agree to give Desjardins Insurance a new declaration within 30 days in the event of any change in circumstances;• they will provide Desjardins Insurance any missing information on their ‘‘Declaration of tax residence’’ within 90 days;• they will provide Desjardins Insurance any business or trust number missing from section A2 - Policyowner - Corporation, trust or other entity (page 2) within 90 days.

Note: If the policyowner is a corporation, trust or other entity, the person authorized to sign on behalf of the policyowner must indicate their name and title and sign below. The Identity Verification Supplementary Form (08295E) must be completed for the reinstatement of any life insurance contract with cash surrender values or a savings component, and the supporting documentation must be attached to the reinstatement application.

X XSignature of policyowner 1 - Individual Signature of proposed insured 1

including children age 14 or older (Quebec) and age 16 or older (provinces other than Quebec)

X XSignature of policyowner 1 - Individual Signature of proposed insured 2

including children age 14 or older (Quebec) and age 16 or older (provinces other than Quebec)

X XSignature of guardian for children under age 18 (Quebec) or legal representative for children under age 16 (provinces other than Quebec)

Name and title of the person authorized to sign on behalf of the policyowner (if the policyowner is a corporation, trust or other entity)

X XSignature of supervisor (for Quebec only) Signature of the person authorized to sign on behalf of the policyowner

(if the policyowner is a corporation, trust or other entity)

X XSignature of representative / Check if a trainee Date (yyyy/mm/dd)

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F - Notice applicable to MIB, Inc. (Give to policyowner)InformationregardingtheinsurabilityofthepersontobeinsuredwillbetreatedasconfidentialbyDesjardinsInsurance,itsreinsurersandMIB,Inc.,anon-profitmembershiporganizationofinsurancecompaniesthatoperatesaninformationexchangeonbehalfofitsmembers.IfyousubmitanapplicationforlifeorhealthinsurancecoverageforanindividualorabenefitclaimforaninsuredtoanotherMIB,Inc.membercompany,uponrequest,MIB,Inc.willsupplysuchcompanywiththeinformationithasonfileaboutthisperson.

MIB, Inc. receives personal information for which the collection, use and disclosure is governed by the Personal Information Protection and Electronic Documents Act (PIPEDA) and provincial laws. Accordingly, MIB, Inc. has agreed to protect such information in a manner that is substantially similar to Desjardins Insurance’s privacy and personal information protection practices and in accordance with applicable laws. As a U.S.-based company, MIB, Inc. is also bound by U.S. laws regarding the disclosure of personal information. If you have any questions about MIB, Inc.’s commitment to ensuring the confidentialityofinsureds’personalinformation,contacttheMIB,[email protected].

Uponrequest,MIB,Inc.willdisclosealloftheinformationinaninsured’sfiletothatinsured.InsuredscancontactMIB,Inc.at416-597-0590. Insureds who dispute the accuracy of the information MIB, Inc. has on record for them can seek a correction in accordance with the procedures set forth on MIB, Inc.’s websiteatwww.mib.com.TheycanalsowritetoMIB,Inc.’sinformationofficeat330 University Avenue, Suite 501, Toronto, Ontario M5G 1R7.

DesjardinsInsuranceanditsreinsurerscanalsoreleaseinformationfromtheirfilestootherinsurancecompaniestowhichanapplicationforlifeorhealthinsuranceorabenefitclaimhasbeensubmitted.ConsumerscanobtainadditionalinformationaboutMIB,Inc.atwww.mib.com.

G - Personal information management (Give to policyowner)DesjardinsInsurancehandlesthepersonalinformationithasonyouinaconfidentialmanner.DesjardinsInsurancekeepsthisinformationonfilesothatyoucanbenefitfromthefinancialservices(insurance,annuities,credit,etc.)itoffers.ThisinformationisconsultedsolelybyDesjardinsInsuranceemployees who need to do so in the course of their work.

Youhavetherighttoconsultyourfile.Youmayalsohaveinformationcorrectedifyoudemonstratethatitisinaccurate,incomplete,ambiguousornotuseful.Todoso,youmustsendawrittenrequesttothefollowingaddress:PrivacyOfficer,DesjardinsInsurance,200,ruedesCommandeurs,Levis,Quebec, G6V 6R2.

DesjardinsInsuranceusesserviceproviderslocatedoutsideofCanadatoperformcertainspecificactivitiesinitsnormalcourseofbusiness.Assuch,personalinformation may be transferred to another country and be subject to the laws of that country. For information about Desjardins Insurance’s policies and practices regarding the transfer of personal information outside of Canada, visit the Desjardins Insurance website at www.desjardinslifeinsurance.com or write totheDesjardinsInsurancePrivacyOfficerattheaddressindicatedabove.ThePrivacyOfficercanalsoansweranyquestionsaboutthetransferofpersonalinformation to service providers located outside of Canada.

The following paragraph applies only if this form is submitted by a representative of Desjardins Insurance or a representative affiliated with Desjardins Insurance.

Desjardins Insurance can send promotional information or offer new products to individuals whose names appear on its client list. Desjardins Insurance may also give its client list to another component of the Desjardins Group for the same purposes. If you do not want to receive such offers, you may have yournameremovedfromthelistbysendingawrittenrequesttothePrivacyOfficeratDesjardinsInsurance.

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G - Specific consent

Applicable to Quebec only

Whenoneofourrepresentativesoffersyoufinancialproductssuchasinsuranceandannuities,wewishtoobtainfromyoucertainrelevantinformationofapersonaland/orfinancialnature.Forspecificsonthecontentofeachoftheseinformationcategories,pleasereadtheothersideofthispage.Pleaseauthorize, in the table below, the “Required information categories to be accessed” for which you give consent.

AfterreadingtheNoticeofspecificconsentshownontheback,I,theundersigned,agreethattheinformationthatDesjardinsFinancialSecurity,FinancialServices Firm holdsconcerningmebeusedatthetimeofthefinancialservicesofferofinsuranceandannuities.

This consent will be valid until it is cancelled or until the cancellation date indicated below.

Identificationandsignature–policyownerandinsured Required information categories to be accessed and client’s authorization

First and last name Date of birth (yyyy/mm/dd)

Personal Yes No

Financial Yes No

Cancellation date (if applicable)

Signature Date of signature (yyyy/mm/dd)


Personal Yes No

Financial Yes No




Personal Yes No

Financial Yes No




Personal Yes No

Financial Yes No




Personal Yes No

Financial Yes No




Personal Yes No

Financial Yes No



In accordance with the Act respecting the protection of personal information in the private sector, you may request access to the information that we hold pertaining to you.

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G - Specific consent (cont.)

G1 - Notice of specific consent

You are free to grant or refuse this consentSection 92 of the Actrespectingthedistributionoffinancialproductsandservices

What you must know • At this date, we hold certain information relating to you.• We require your consent to allow some of our representatives to have access to this information.• These representatives will also have access to any update of the information done during the period of validity of the consent.• These representatives will use the information available in order to solicit you for the purchase of new financial products and services.

You are free to set the period of validity of your consent• Ifyougrantconsentforanundeterminedperiodoftime,youmayatanytimeterminateitbyrevokingit.Attheendofthisform,youwillfindarevocationnotice

model that you may use for this purpose or as a basis for preparing your own notice.• Ifyouwishtograntconsentforalimitedperiodoftime,youmaydosobydeterminingthisperiodyourself.Thisformprovides,inthe“Specificconsent”section,

a place where you may write down the period of validity desired.

The Act Respecting the Distribution of Financial Products and Services gives you important rights.

Withoutthisspecificconsent,DesjardinsFinancialSecurity,FinancialServicesFirmmaynotusethisinformationforapurposeotherthanthepurposeforwhichitwas collected. Desjardins Financial Security, Financial Services Firm cannot compel you to give your consent or refuse to do business with you if you refuse to give it. Section94oftheActprotectsyou.Forfurtherinformation,contacttheAutoritédesmarchésfinanciersat:

Quebec: 418-525-0337 Montreal: 514-395-0337 Toll-free: 1-877-525-0337

Weholdcertaininformationpertainingtoyouthatwehavecollectedwhenofferingfinancialproductsandservicesincludinginsurance,annuities,creditandother related services.

G2 - Required information categories to be accessed

Personal:forexample,firstandlastname,dateofbirth,sex,address,phonenumber,occupation.

Financial:forexample,personalandhouseholdincome,dependents,otherinsurancecontractsandannuitiesinforce,investments,financialstatement and, if a company, statement of assets and liabilities.

G3 - Model of revocation of specific consentFirst name and last name (please print) Contract number

Address (No., street, apt.) Date of birth (yyyy/mm/dd)

City Province Postal code 10-digit phone number

I hereby revoke the specific consent given to:Desjardins Financial Security, Financial Services Firm200,ruedesCommandeurs,Lévis,QuebecG6V6R2

by the following notice:

On (yyyy/mm/dd):

I, the undersigned, , hereby notify you that I amPolicyowner’sorinsured’sfirstnameandlastname

cancellingthespecificconsentauthorizingthecommunicationofmypersonalinformationfornewpurposes.

Consent given to you on: Date of consent (yyyy/mm/dd)

XSignature of policyowner or insured