comprehensive application form -...

RepresentativeName RepresentativeCode %Split SalesOfficeName SalesOfficeCode (6digits) (5alphanumeric)

www.standardlife.ca

TheStandardLifeAssuranceCompanyofCanada

(*FinancialSecurityAdvisorinQuebec)

5071H-01-2010

Protection Solutions

Comprehensive Application Form

ImportantInstructionstoStandardLife

Representative* InformationIMPORTANT:Informationneededtoprocessthisapplicationformandtopayyourcommission.Missinginformationwillcausedelays.Theservicingrepresentative(forStandardLife’srecords)willbethepersonwhosignsthisapplicationform,unlessotherwiseindicated.Pleaseprintclearlythroughouttheapplicationform.

ThisComprehensiveApplicationformincludesmedicalquestions.Ifyoudon’twanttoaskmedicalquestionsuseourExpressApplicationform.AdditionalquestionnairesmaybefoundinyourWealthcaresoftwareoratwww.standardlife.ca.

Life Insurance and Critical Illness Insurance

I do not have a representative code with Standard Life. This is my first application.



5071H-01-2010

ApplicationNumber:

Page1

Driver’sLicenseNumber ProvinceofIssue

Idon’thaveadriver’slicense,Ihaveindicatedanotherdocumentbelow:BirthCertificate PassportRecordofLanding PermanentResidentcardProvincialMedicalCard(exceptifissuedinON,MB,NBandPEI)

ProvinceofIssue(ifapplicable) Document#

Driver’sLicenseNumber ProvinceofIssue

Idon’thaveadriver’slicense,Ihaveindicatedanotherdocumentbelow:BirthCertificate PassportRecordofLanding PermanentResidentcardProvincialMedicalCard(exceptifissuedinON,MB,NBandPEI)


Occupation

Tel-Bus. – –

EarnedAnnualIncome

$NetWorth

$OtherAnnualIncome

$Employer’sName

Street Address

City

Province

Nature of Business

Unit/Suite

PostalCode

Yearswiththisemployer

Occupation

Tel-Bus. – –

Employer’sName

Street Address

City

Province

Nature of Business

Unit/Suite

PostalCode

Yearswiththisemployer

EarnedAnnualIncome

$NetWorth

$OtherAnnualIncome

$

Street Address Unit/Apt.

City

Province

Tel-Res. – –

Fax – –

E-mail

PostalCode

Street Address Unit/Apt.

City

Province

E-mail

PostalCode

Tel-Res. – –

Fax – –

B1 • Proposed InsuredFormorethan2applicants,useadditionalapplicationsasrequired.Deletetheapplicationnumberoneachadditionalapplicationandenterthenumberofthefirstone.Submitallapplicationstogether.

AgeNearest:whichbirthdayislessthan6monthsaway:yourlastoryournext?

SINisrequiredfortaxpurposes.(applicabletoPerspectaandWholeLife)

Home address

Employment details

Insured(s) ID verificationValid proof of the insured’s identitymustbeobtainedthrough a government issued identificationdocument(anexpireddocumentisnotvalid).Adriver’slicenseistheeasiestwaytoprovidethistous.Ifyoudon’thaveadriver’slicenseyoucanchooseoneoftheotherdocumentslisted.

Proposed Insured 1

Mr Mrs Miss Ms Other:

PermanentCanadianResident Yes NoTypeofResident:

Canadian Citizen Other (PleaseprovidedetailsinSectionG3) Landed Immigrant

Years in Canada Sex Male FemaleSmokerClassAppliedfor Smoker Non-SmokerCircleProfile:12345(forPerspecta,WholeLifeandTerm10/20)

DoyouunderstandandspeakEnglish? Yes No

LanguageofCorrespondence English FrenchNewApplication OR AdditiontoexistingPolicyNumber:

Proposed Insured 2

Mr Mrs Miss Ms Other:

PermanentCanadianResident Yes NoTypeofResident:

Canadian Citizen Other (PleaseprovidedetailsinSectionG3)

Landed Immigrant

Years in Canada Sex Male FemaleSmokerClassAppliedfor Smoker Non-SmokerCircleProfile:12345(forPerspecta,WholeLifeandTerm10/20)

DoyouunderstandandspeakEnglish? Yes No

SameasProposedInsured1

/ / / /

First Name and Initial First Name and Initial

Last Name Last Name

MaidenName(ifdifferent) MaidenName(ifdifferent)

DateofBirth(DD/MM/YYYY) DateofBirth(DD/MM/YYYY)Age Nearest Age NearestSIN (see note left margin) SIN (see note left margin)

PlaceofBirth:Province PlaceofBirth:ProvinceCountry Country

A – Basic Information

B – Proposed Insured(s) and Owner Details

5071H-01-2010

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Page2

B2 • Beneficiary DesignationYouneedtotelluswhogetsthemoneyonceitbecomespayableunderyourcoverages.Ifyoudon’ttellus,wewilldesignateadefaultbeneficiaryforyouasfollows:

ForLifeInsurance,the •beneficiarywillbetheownerortheowner’sestate.ForChildProtectionRiders,the •beneficiarywillbetheowner.ForCriticalIllnessBenefits,the •beneficiarywillbetheinsured.ForCriticalIllnessReturnof •PremiumonDeath(ROPD)and/orReturnofPremiumonSurrender(ROPS),thebeneficiarywillbetheownerortheowner’sestate.

Whereaminorisdesignatedasabeneficiaryitisrecommended thatatrusteebeappointedforclaimspurposes.

AddanyspecialinstructionstoRepresentativereportpage10.

B3 • The Designated Owner is:FormultipleownersandBusiness/Non Business OrganizationyoumustassignonepersontodealwithStandardLife.

Ifallownerspredeceasethelifeinsured,thelifeinsuredwill becometheowner.

The Proceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulations requirethatweobtainadditionalidentificationinformationinthecasewheretheownerisacorporationoranentity,orisacharitableorganization.Completeform PC 6330 (Client Identification Supplementary Information) if the ownerisacorporationorentityorcharitableorganization.

First Name Last Name Age Relationship to Proposed Insured %

BeneficiaryforLifeInsuranceCoverages

Insured1

Insured 2

PrimaryBeneficiary ContingentBeneficiary

Insured1

Insured 2

PrimaryBeneficiary ContingentBeneficiary

Child RidersPrimaryBeneficiary ContingentBeneficiary

BeneficiaryforCriticalIllness(CI)Coverages CIBenefit ROPD ROPS %

Insured1

Insured 2

Insured1

Insured 2

Insured1

Insured 2

NameofTrusteeforMinorChildren

If you live outside of Quebec: all beneficiaries are revocable (may be changed by owner) unless you write to Standard Life and tell us they are irrevocable.

If you live in Quebec: all beneficiaries are revocable except your spouse who is irrevocable (need spouse’s permission to change). If you want your spouse to be a revocable beneficiary then initial this box.

In Quebec if you use share by percent (%) in unequal shares and one of the beneficiaries dies then the share belonging to that beneficiary will revert back to the Owner or to the Owner’s estate if the Owner has died. However by designating Beneficiaries in equal shares this will not be the case.The taxation of any benefits paid under a Protecta coverage remains subject to Canada Revenue Agency interpretation, which may change over time as a result of changes to the law or changes to administrative practices. Anyone purchasing Protecta coverage should discuss the implications with their accountant or tax advisor.

Proposed Insured 1 (Go to B4) Proposed Insured 2 (Go to B4) Jointly Proposed Insured 1 and 2 (Tell us which one will deal with Standard Life below) (Go to B4) Business/Non Business Organization (Complete this section) Other (Complete this section)

Multiple owners:AnydocumentsignedsubsequenttothisapplicationbytheSpecifynumberofOwners: designatedOwnerwillhavethesameeffectasifithadbeensignedbyallOwners.WeareherebyappointingthefollowingpersontodealwithStandardLife:

First&LastName(andCompanyNameifapplicable)Male

Female

DateofBirth(DD/MM/YYYY)

/ /Street Address Unit / Apartment City

Province PostalCode Tel-Res. – –

Tel-Bus. – –

Occupation Relationship to insured SIN

5071H-01-2010

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Owner ID verificationValidproofofallownersidentitymustbeobtainedthrough a government issued identificationdocument(anexpireddocumentisnotvalid).Adriver’slicenseistheeasiestwaytoprovidethistous.Ifyoudon’thaveadriver’slicenseyoucanchooseoneoftheotherdocumentslisted.ForQuebec,theMedicalcardcannotberequested,butisacceptedifelectedbytheProposedInsuredforidentificationpurposes.For Business/Non business organizationwerequirevalidproofofthebusinessexistence.Chooseoneofthefollowingmostaccessibledocumentslistedandsendusacopy.

Multiple owner ID verificationValidproofofallownersidentitymustbeobtainedthrough a government issued identificationdocument(anexpireddocumentisnotvalid).Adriver’slicenseistheeasiestwaytoprovidethistous.Ifyoudon’thaveadriver’slicenseyoucanchooseoneoftheotherdocumentslisted.

ForQuebec,themedicalcardcannotberequested,butisacceptedifelectedbytheProposedInsuredforidentificationpurposes.

For Business/Non Business Organizationwerequirevalidproofofthebusinessexistence.Chooseoneofthefollowingmostaccessibledocumentslistedandsendusacopy.

The Proceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulations requirethatweobtainadditionalidentificationinformationinthecasewheretheownerisacorporationoranentity,orisacharitableorganization.Completeform PC 6330 (Client Identification Supplementary Information) if theownerisacorporationorentityorcharitableorganization.

Foradditionalowners,provide the same information insectionG2.

B4 • Contingent OwnerCompletethissectionifyouwantanotherpersontobetheowner,iftheownerdies.

Ifallownerspredeceasethelifeinsured,thelifeinsuredwillbecometheowner.

Ow

ner

Driver’sLicenseNumber ProvinceofIssue ExpiryDate DateofBirth(DD/MM/YYYY)

/ /PlaceofBirth:Province Country

Idon’thaveadriver’slicense,Ihaveindicatedanotherdocumentbelow:BirthCertificate Passport RecordofLanding ProvincialMedicalCard(exceptifissuedinON,MB,NBandPEI) PermanentResidentcard


Business/Non Business Organization CertificateofCorporateStatus AnyrecordthatconfirmstheexistenceofaBusiness ArticlesofAssociation Articles/LetterorIncorporation PartnershipAgreement

The legal Name of the Organization Provinceofregistration

Address IncorporationNumber

Ow

ner 2

First&LastName(andCompanyNameifapplicable)Male Female


/ /Driver’sLicenseNumber ProvinceofIssue ExpiryDate

PlaceofBirth:Province Country






Ow

ner 3

First&LastName(andCompanyNameifapplicable) Male Female


/ /Driver’sLicenseNumber ProvinceofIssue ExpiryDate

PlaceofBirth:Province Country






Proposed Insured 1 (Go to C) Proposed Insured 2 (Go to C) Jointly Proposed Insured 1 and 2 (Tell us which one will deal with Standard Life below) (Go to C) Corporate Ownership (Complete this section) Other (Complete this section)

First&LastName(andCompanyNameifapplicable) IncorporationNumberMale Female


/ /Relationship to insured SIN Tel-Res.

– –Tel-Bus. – –

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C1 • Perspecta (Universal Life)

Perspecta Account Value Allocation at Death(onlyformultiplelives)

Perspecta Shelter Optimizer

Perspecta Death Benefit Option

Perspecta Investment InstructionsThe premiums and additional depositswillbeallocatedaccordingtotheclientillustrationthatmustbeattachedtothisapplicationform.

Ifyouwouldliketoallocatethe premiums or deposits differentlythanontheclientillustration,enterthename(s)oftheaccountstogetherwiththeallocationpercentages.

Perspecta Deduction AccountPleaseselectonlyoneoption.

Perspecta Statement

C2 • Whole LifeIndicatecoverageandSumInsuredforeachProposedInsured.

ProportionalfromeachAccount (default) DailyInterestAccount 1YearTermAccount

SpecifyNameofIndexedAccount,AssetAllocationAccountorManagedAccount:

ProportionaltoPerspectaCoverageSumInsured(default)

100%ontheDeathcausingterminationofthelastPerspectaCoverage

SpecifypercentontheDeathcausingterminationofeachPerspectaCoverage: %

No Increase, No Decrease (default) Yes, use Shelter Optimizer (select below)

Increaseonly

OnExemptTestFailure TransfertoTransitAccount(default)OR PartialSurrender(withdrawal)chequesendtoowner

Single and Joint Lives Increasing(default) Level Hybrid

Multiplelives Multiple-Increasing(onlyoptionformultiplelives)

Perspecta Single Life Perspecta Joint First-to-Die Perspecta Joint Last-to-DiePerspectaCostofInsurance Level (default) or YRT-100 or YRT-85/20

Sum Insured ProposedInsured1 ProposedInsured2

$ $

Joint Last-to-Die only PerspectaJointLast-to-Die PaymentofAccountatFirstDeathSpecifypercentpaid

% PaiduponFirstDeath

Choose the product you want and go directly to that section. Perspecta (Go to C1) Whole Life (Go to C2) Term 10/20 (Go to C3) Protecta (Critical Illness) (Go to C4) For all Child Riders (Go to C6)

Original Contract Specify Notbefore Sum Insured minimum

$ years IncreaseandDecrease(defaultifYesisselected)

Decreaseto:

WhowillbethebeneficiaryofAccountpayment?

Frequency Yearly(default) QuarterlyIncludeTransactionDetails Yes (default) No

Go to D1 unless you have Riders or Benefits to add

Investment Account Name Percentage

Total of all Accounts 100%

Proposed Insured 1

Proposed Insured 2

Single Life Joint First-to-Die Joint Last-to-Dietoage100 to age 65 25year Amount

$ to age 75 30year 20year

Single Life Joint First-to-Die Joint Last-to-Dietoage100 to age 65 25year Amount

$ to age 75 30year 20year

C – Product Choice

5071H-01-2010

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Proposed Insured 1 Proposed Insured 2Amount $

Amount $

Amount $

Amount $

Amount $

Amount $

C3 • TermIndicatecoverageandSumInsuredforeachProposedInsured.

C4 • Protecta (Critical Illness)ROPD–ReturnofPremiumon Death

ROPS–ReturnofPremiumon Surrender

ROPD&ROPS–ReturnofPremiumonDeathorSurrender

C5 • Benefits

C6 • Children’s Coverage & RidersLife Insurance: CPR–Children’sProtectionRider ECPR–EnhancedChildren’s ProtectionRider

Critical Illness Insurance: PCP–ProtectaChildPlan PCR–ProtectaChildRider ROPD–ReturnofPremiumon Death

ROPS–ReturnofPremiumon Surrender

ROPD& ROPS–ReturnofPremiumonDeathorSurrender

For Protecta Child go to C5

Proposed Insured 1Protecta Protecta

EnhancedROPD ROPS ROPDand

ROPSPlan Rider Amount

10 10 $

65 65 Single Life Joint Single Life Joint $

75 75 $

100 100 $

Proposed Insured 2Protecta Protecta

EnhancedROPD ROPS ROPDand

ROPSPlan Rider Amount

10 10 $

65 65 Single Life Joint Single Life Joint $

75 75 $

100 100 $


Proposed Insured 1


Proposed Insured 2

Term10R&C PlanSingleLife Amount

$


$ PlanJointFirst-to-Die PlanJointFirst-to-Die Rider Single Life Rider Single Life Rider Joint First-to-Die Rider Joint First-to-Die


$


$ PlanJointFirst-to-Die PlanJointFirst-to-Die Rider Single Life Rider Single Life Rider Joint First-to-Die Rider Joint First-to-Die

Allpolicycoverages Owncoverage

AccidentalDeathBenefit(n/aforProtectaCI)

GuaranteedInsurabilityBenefit(n/aforProtectaCI)Survivor’sInsuranceBenefit(SIB)to age 65 age70 (forJointFirst-to-Dieonly)

WaiverofPremium WaiveronDeathandDisability

Perspecta Universal Life Waivers

WaiverofCostsonDisability(Choose one)

EnhancedWaiveronDisability,amounttobewaivedandduration 10Yrs 20Yrs age50 age60

WaiveronDeathandDisability,amounttobewaived

Allpolicycoverages Owncoverage

DothechildrenlivewiththeOwner? Yes NoLife&CriticalIllness:areallchildrenbeinginsuredequally? Yes No (Telluswhybelow)Indicatethecriticalillnesscoverageamountoftheparents.

Mother$

Father$ Ifnone,telluswhyhere:

First&LastName DateofBirth Sex SumInsured Relationship SpecifyRider (ProposedChild) DD/MM/YYYY Amount to Owner Chosen

$

$

$

Male

Female/ /

ProposedInsured1 OR ProposedInsured2

Male

Female/ / Male

Female/ /

Go to D1 unless you are adding children’s coverage and/or riders

1

2

3CPR ECPR PCP PCRROPD ROPS ROPD&ROPS

CPR ECPR PCP PCRROPD ROPS ROPD&ROPS

CPR ECPR PCP PCRROPD ROPS ROPD&ROPS

Amount $

Amount $

Amount $

Amount $

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BilltoProposedInsured1(GotoE) BilltoProposedInsured2(GotoE) BilltoOwner(GotoE) Bill to Other (Completethissection)

First&LastNameorCompanyName DateofBirth(DD/MM/YYYY)

/ /Billing Address Unit/Suite

City Province PostalCode

Occupation RelationshiptoOwner IfBusiness:RegistrationNumber PlaceofRegistration

TypeofDocument Document#

ProvinceofIssue(ifapplicable) ExpiryDate

D1 • Premium payment

How will the first premium be paid?

How will future premiums be paid?

What draw day do you want?

Who is paying the premium?Completethissectiononlyifthepremiumpayerisnottheowneror one of the insured(s) and sign onpage9.

IndicateBillingAddressifnotownerorinsured(s).

Premium Payer ID verification(SeesectionB3fortypesofIDdocumentsaccepted)

E1 • Insurance history questionsTobecompletedbyallapplicantswhoareProposedInsuredson thisapplicationincludinganyownerwhoisapplyingfor waiverbenefits.

Forlifeinsurance,ifaProposedInsured has applied for other insuranceinthelast12monthswithStandardLifeorwithanotherInsuranceCompany,thetotalsum insured applied for during thisperiodwillbeaddedtogethertodeterminethenecessaryunderwritingrequirements.

Replacement / Change InsuranceReplacementformsarerequiredinallcases.Failuretocompletethemwillresultinadelayinyourpolicybeingissued.

Additional details

D – Premium PaymentSelected/InitialPremium Amount

$ PerspectaAdditionalDepositatIssue Amount

$

ChequeattachedAmount$ Withdrawfrombankaccount C.O.D.

(Attachspecimencheque)

AnnualDirectBilling Semi-annualDirectBilling Pre-authorizeddebitagreement: Annual Semi-annual Quarterly Monthly

(PAD–attachspecimencheque) AddtoexistingPADagreement: Whatisthesourceoffunds:

PolicyNumber

There-presentmentofapaymentreturnedduetonot-sufficientfundsorfundsnotclearedcanoccuronlyonceandmustbewithin30daysoftheoriginaldebit.Ifthepaymentisreturnedasecondtime,themethodofpremiumpaymentwillbealteredtoannual,directbillingandcannotbechangeduntilthenextpolicyanniversary.Theproportionoftheannualpremiumcalculatedtothenextpolicyanniversarybecomesimmediatelypayable.AnewPADagreementisrequiredtoreturntothePADmethodofpayment.

Willthisapplicationreplaceorcauseachangein,orinvolveasubstantialloanunderanyexistinginsuranceorannuitycontract?Ifso,indicatethecontract(s)affected.InadditionprovincialreplacementformsmustbesubmittedimmediatelywiththisapplicationintheprovinceofManitoba;within5workingdaysintheprovinceofQuebec;andwithin3workingdaysinallotherprovinces.

Proposed Proposed

All Proposed Insured 1 Insured 2 Children under this application

Yes No Yes No Yes No

ForallProposedInsureds,thisisthefirsttimeLifeorCriticalIllnessInsurancehasbeenappliedfor (excludinggroupbenefits)(gotoE2).OtherLifeorCriticalIllnessInsurancearependingorinforce(completethissection).

Option a,b,c,d,e,f

TypeofInsurance Amount AccidentalDeath

BenefitAmount Company Date Issued(DD/MM/YYYY) Purpose

$ Business Personal

$ Business Personal

$ Business Personal

$ Business Personal

$ Business Personal

E – Information Regarding Proposed Insured(s) and Owner

Options: a)ProposedInsured1inforce c)ProposedInsured2inforce e)Ownerinforce b)ProposedInsured1pending d)ProposedInsured2pending f)OwnerPending

DrawDayonIssueDateORSpecifyDate: Datebetween1and28 Drawdayscannotbeaftertheissuedateor the 29th,30th,or31stofanymonth.

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E2 • Purpose of InsuranceFailure to complete this section including the question relating to bankruptcy will result in a delay in your policy being issued.

What is the purpose of Insurance?

Additional Details

E3 • Smoking habits and use of nicotine productsIndicateifyouuseorhaveused anyofthefollowingproductsaswellasthequantityandthedatelastused.

E4 • Temporary Insurance Agreement (TIA) questionsTobecompletedforeachInsuredinallcases.

More medical questions will follow, as non-medical, or Paramedical, or Medilife, or Medilife (internist).

Additional Details

Proposed Insured 1 Proposed Insured 2

Details Qty Frequency Date Last Used Details Qty Frequency Date Last Used Yes No DayMonthYear DD/MM/YYYY Yes No DayMonthYear DD/MM/YYYY

Cigarettes / / / /Cigarillos / / / /Cigars(anytype) / / / /NicotinePatch / / / /NicotineGum / / / /ChewingTobacco / / / /Pipe / / / /WaterPipe / / / /Marijuana / / / /Other(e.g.BetelNuts) / / / /

1. Haveyoueverhadanapplicationforlife,health,criticalillnessordisabilityinsurance,reinstatementorchangeeither:rated,declined,postponed,modified,ornotproceededwith?

2. Haveyouwithinthepast90days,otherthanfornormalchildbirth,beenadmittedoradvisedtobeadmittedtoahospitalorothermedicalfacilityorhaveyouhadanysurgeryperformedorrecommended?

3. Haveyouinthepast5yearseverhad,beentoldyoumayhaveorbeenadvisedtohavetestsfor:cancer,drugoralcoholabuse,heartorcirculationproblemssuchasstroke,highbloodpressure,chestpain,unexplainedinfections,orhaveyoueverhad,beentoldyoumayhave,beenadvisedtohavetestsfororreceivedinformationindicatingpossibleexposuretoAIDS(HIV)?

4. HaveyouanyintentiontoresideortraveloutsideofNorthAmericaorWesternEuropewithinthenextyear?

Proposed Proposed

All Proposed Insured 1 Insured 2 Children under this application





Have any of the insureds or any companies owned by the insured declared bankruptcy within the past 3 years? Yes No If Yes,select: Personal Corporate

Please provide details including date of discharge:

Personal Insurance: IncomeProtection EstateConservation Other:

Business Insurance: KeyPerson Buy-SellAgreement Other:

Financial Information for Business Insurance:Nameofthebusiness Natureofthebusiness Numberofyearsthebusiness

hasbeenactive

Total Assets$

TotalLiabilities$

FairMarketValue$

Netprofitaftertaxes:Currentyear$

Previousyear$

Percentageownership

%Arealltheremainingpartnersproportionatelyinsured?Ifnot,explainwhy?

Howwastheamountofinsurancedetermined?

5071H-01-2010

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F1 • Each of the Undersigned:1. Agreethatinadditiontothisapplication,asupplementarymedicalandlifestylequestionnaire(s)maybecompletedeither:directlywiththe

representative,orinaTAPEDtelephoneconversationwithamedicalprofessional,orduringavisitwithamedicalprofessional.TheProposedInsuredsagreethatanysuchinformationwillbeusedtoconsiderthepolicyandtheresultoftheunderwritingassessmentbecommunicatedtotherepresentative.TheProposedInsuredsagreeaswelltoreviewthisinformationuponreceiptofthepolicyandtoadviseStandardLifeimmediatelyifthereisanyinaccurate,falseinformationorachangeininsurabilitybetweenthetimeofapplicationandthetimeofdelivery.

2. Understandthatifanystatementsoranswersrecordedarefoundtobeincorrectorincomplete(including,withoutlimitation,thosemadeforthepurposeofjustifyingtheuseofnon-smokerratesforaProposedInsuredunderthepolicyappliedfor),thepolicyshallbenullandvoidinrespectoftheProposedInsured.

3. ImayrevokemyPADauthorizationatanytimebyproviding10daysverbalorwrittennotice.Toobtainacancellationform,orformoreinformationonmyrighttocancelthisPADAgreement,Imaycontactmyfinancialinstitution,StandardLifeorvisitwww.cdnpay.ca.Imaywaivetherighttoreceivepre-notificationoftheamountofthePADandthereforeagreethatIdonotrequireadvancenoticeoftheamountofPAD(s)beforethedebitisprocessed.Ihavecertainrecourserightsifanydebitdoesnotcomplywiththisagreement.IhavetherighttoreceivereimbursementforanydebitthatisnotauthorizedorisnotconsistentwiththisPADAgreement.Toobtainmoreinformationonmyrecourserights.Imaycontactmyfinancialinstitution,StandardLifeorvisitwww.cdnpay.ca.Ifthepolicyisforindividualcoverage,thenthePADwillbesetupasapersonalPADandifthepolicyisforcorporatecoverage,thenthePADwillbesetupasabusinessPAD.

4. UnderstandandagreethatwhereaTemporaryInsuranceAgreement(TIA)hasbeenissuedrelatingtoLifeInsurance,theamountpayableunderthisandallotherTIAswithStandardLifeoneachProposedInsuredislimitedtothelesserofonemilliondollars($1,000,000)andthetotalamountoflifeinsuranceappliedfor(includinganyAccidentalDeathBenefits).

5. UnderstandandagreethatwhereaConditionalInsuranceAgreementhasbeenissuedrelatingtoCriticalIllnessInsurance,theamountpayableshallbetheLESSERofthetotalamountofCriticalIllnessInsuranceappliedforintheapplication(s),and$500,000,lessanyotherCriticalIllnessbenefitspayablebyStandardLife.

6. AcknowledgethatifthisapplicationisforanadultCriticalIllnessInsurance,Ihavebeenmadeawareofthe2ProtectaproductsofferedbyStandardLifeandthateachcoversadifferentnumberofillnesses(ProtectaandProtectaEnhanced).ThecoverageIhaveselectedhereinisappropriatetomyneedsatthistime.

7. AgreethatthisApplicationandtheattachedTemporaryInsuranceAgreementforlifeinsurance,andifapplicabletheConditionalInsuranceAgreementforCriticalIllness,aregovernedbythelegislationoftheOwner’sprovinceofdomicile.

8. Iauthorizeanyhealthcareprofessional,hospital,publicorprivatehealthorsocialservicesestablishment,anyinsurancecompany,oranyotherinstitutionorpersonthathasanyrecordsorknowledgeofmeormyhealth,toprovideandexchangesuchinformationorrecordstoStandardLife’sagents,distributionandmarketingpartnersoritsreinsurers.

9. AuthorizeStandardLife’sagents,distributionandmarketingpartners,forunderwritingandadministrationofinsuranceandclaimspayingpurposesonly:togatheronlythatinformationnecessaryfortheobjecttothefile,fromanypersonororganizationthathaspersonalinformationrelatingtome,includingotherinsurers,physiciansandmedicalinstitutions,theMedicalInformationBureau,investigationandcreditreportingagencies,andallpersonsororganizationslikelytohavepersonalinformationrelevanttotheobjectofthefile;todiscloseonlythenecessarypersonalinformationrelatingtometothesesamepersonsandorganizations;andtorequestapersonalinvestigationreportrelatingtome.Thisauthorizationisvalidfortheperiodrequiredtoachievetheendsforwhichitwasrequested.IacknowledgereceiptofMedicalInformationBureau notice.

10. Ideclarethattheforegoingstatementsaretrue,completeandcorrectlyrecordedandshallformpartoftheapplicationforlifeinsuranceorcriticalillnesswithStandardLife.ForthepurposeofevaluatingtheriskundertheapplicationforlifeinsurancewhichhasbeenmadetoStandard Life orforanyclaimspurposes,Iauthorizeanylicensedphysician,medicalpractitioner,hospital,clinicorothermedicallyrelatedfacility,insurancecompany,MedicalInformationBureau,orotherorganization,institutionorpersontogiveanyinformationregardingmetoStandard Life or its reinsurers.Aphotocopyofthisauthorizationshallbeasvalidastheoriginal.

Minors:AsignatureisrequiredbyallProposedInsuredsage14andoverintheprovinceofQuebecandage16andoverinallotherprovinces.

IfownedbyBusiness/NonBusinessOrganization,supplysignatureofanauthorizedsigningofficer.

ProvinceofSignature this dayof ,20


Proposed Insured (minor) Proposed Insured (minor)

Consenting Parent/Guardian (ifjuvenileApplicationoranychildren’sRider) Owner(onlyrequiredifdifferentthanProposedInsured1or2)

Owner(onlyrequiredifdifferentthanProposedInsured1or2) Owner(onlyrequiredifdifferentthanProposedInsured1or2)

F – Declarations and Authorizations

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F2 • Premium Payer SignatureIf the Premium Payer is different from Proposed Insured 1 and 2 and Owner, only then do you need to sign here.

F3 • Representative Signature

IauthorizeStandardLifetobegindeductionsasinstructedforregularrecurringpremiumpayments,regularinvestmentplanpaymentsand/orforone-timeorsporadicpaymentsuponmyverbalorwrittenrequestfromthefinancialinstitutionindicatedontheattachedspecimencheque,oranyotheraccountatanyfinancialinstitutionsubsequentlydesignatedbyme.Ifurtherauthorizesuchfinancialinstitutiontodealwiththesewithdrawalsasthoughtheyweresignedbyme.

ProvinceofSignature this dayof ,20

Premium Payer

Proceeds of Crime (Money Laundering) and Terrorist FinancingThe Proceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulationsrequirethatweobtainadditionalidentificationinformationinthecasewherethe:•Owner*isacorporationoranentity;•Owner*isacharitableorganization;•Owner*makesapremiumpaymentof$100,000ormore.

Doesoneormoreoftheabovesituationsapply? Yes (Complete Client Identification Supplementary Information form PC 6330). No

Third Party DeterminationIhavemadeareasonableefforttodetermineiftheowner(s)*is(are)actingonbehalfofathirdparty.Willtheowner(s)*beactingonbehalfofathirdparty?

Yes (Complete Third Party Determination form PC 5097)Iwasunabletodeterminewhethertheowner(s)*is(are)actingonbehalfofathirdparty,orthirdparties,butIhavereasonablegroundstosuspectthatthisisthecase.(Complete Third Party Determination form PC 5097) No

* (& Additional Owner, if applicable). Identification needs to be provided on a separate sheet of paper.

IhaveascertainedtheidentityoftheProposedInsured(s),owner(s)andpremiumpayer inaccordancewiththeProceeds of Crime (Money Laundering) and Terrorist Financing Act and Regulationsbyexaminingtheoriginalandvalididentificationdocumentsforeachofthem. Yes No

Ihavecompletedtheanswerstoquestionsinthisapplicationinthepresenceoftheowner andtheProposedInsured(s)beforethisapplicationwassigned. Yes No

IhavearelationshipwiththeProposedInsured(s).

Yes Typeofrelationship:

HowlonghaveyouknowntheProposedInsured(s): years No

Iholdavalidlicenseinthejurisdictionwherethisapplicationwassigned. Yes No

Ihavedisclosedthefollowinginformationtotheclient(s):• thecompanyorcompaniesIrepresent;• thatIreceivecompensation(suchascommissionsorasalary)forthesaleoflifeandhealthinsurancecompanyproducts;

• thatImayreceiveadditionalcompensationintheformofbonuses,conferenceprogramsorotherincentives;and• anyconflictsofinterestImayhavewithrespecttothistransaction.

Ihaveprovidedtheclient(s)withtheProductDisclosuredocumentfortheproductsold.

Ihavecompletedtheapplicationwiththeclient(s)andtothebestofmyknowledgetheinformationsuppliedwithinthisapplicationforinsuranceisaccurate.

Date(DD/MM/YYYY)

/ /

Representative’sName(inblockletters)

Representative Signature

5071H-01-2010

ApplicationNumber:

Page10

G1 • Underwriting RequirementsForPerspecta,theclientsignaturepagefromtheIllustrationmustbeattachedtothisapplication.

G2 • Representative Notes + Details

Perspecta Whole Life Term 10/20 Protecta (CI)

Attachbar-codedlabel

IhaveorderedthefollowingUnderwritingRequirements:

Proposed Insured 1

Paralife StressECGMedilife ADL Medilife (internist) MVR UHIV InspectorReportBCP FinancialstatementsAPS SHIVECG

UnderwritingRequirementsordereddate(DD/MM/YYYY)

/ /

APSfromDr.Name

at AddressandTel.

UnderwritingRequirementsorderedfrom Keyfacts Medisys Exam-One BodiMetric Hooper Holmes Other(specify):

Proposed Insured 2

Paralife StressECGMedilife ADL Medilife (internist) MVR UHIV InspectorReportBCP FinancialstatementsAPS SHIVECG

G – Representative Report

5071H-01-2010

ApplicationNumber:

Page11

G3 • Additional DetailsIndicate

sectionandnumber (i.e.E3)

Indicatesectionandnumber (i.e.E3)


If no additional details go to H

ApplicationNumber:

5071H-01-2010

5071H-01-2010

5071H-01-2010

ApplicationNumber:

ApplicationNumber:

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H – Notice and Agreements

Instructionstorepresentative:IFALLproposedinsuredsareolderthan30daysandyoungerthanage66,thendetachthisAgreementandgiveittotheowner.Regardlessofwhetheranypremiumhasbeencollectedwiththeapplication,thereisnoConditionalInsuranceAgreementifalltheconditionssetoutbelowandonthereversearenotmet.

Conditional Insurance Agreement – Critical Illness Insurance StandardLifeprovidesfreetemporaryCONDITIONALcriticalillnessinsuranceinaccordancewiththetermssetoutbelowandonthereverse.Thisconditionalinsurance,subjecttotheusualtermsofthepolicyappliedfor,shalltakeeffect:• onthedateonwhichsufficientevidenceofinsurabilityforalltheproposedinsuredsisreceived(hereafterreferredtoastheeffectivedate);and• provideditisdeterminedthatalltheproposedinsuredswerestandardrisksontheeffectivedateinaccordancewithStandardLife’susualunderwritingrulesandpractices.

Temporary Insurance Agreement (TIA) – life insuranceStandardLifeprovidesfreetemporarylifeinsurancecoveragewhileweareconsideringyourapplication.Thisinsurancebeginsonthedateyoucompleteandsignyourapplication.Youareentitledtothiscoverageif:• alltheproposedinsuredsareolderthan15daysandyoungerthanage66;and• alltheproposedinsuredsanswered“no”toallpartsofquestions1to4oftheTIAInsurabilityQuestions(E4,page7)(thereisacopyofthemonthebackofthisAgreement);and• foreachproposedinsured,thetotalamountoflifeinsuranceappliedforislessthan$3,000,001.If,foraproposedinsured,thetotalamountoflifeinsuranceappliedforislessthan$1,000,000theniftheproposedinsureddies,StandardLifewillpaytheamountinsuredtothebeneficiariesdesignatedintheapplication.If,foraproposedinsured,thetotalamountoflifeinsuranceappliedforis$1,000,000ormoretheniftheproposedinsureddies,StandardLifewillpay$1,000,000tothebeneficiariesdesignatedintheapplication.Ifyouhavechosenjoint-first-to-diecoverage,thenStandardLifewillpaywhenthefirstproposedinsureddies.Ifyouhavechosenjointlast-to-diecoverage,thenStandardLifewillpaywhenthelastproposedinsureddies.Ifoneormoreoftheproposedinsuredscommitssuicide,whetherornottheyareofsoundmind,thentheTemporaryInsuranceAgreementisvoidandnopaymentwillbemadebyStandardLife.

Notice to proposed life insureds regarding Medical Information Bureau (MIB)Informationoneachoftheproposedinsuredswillbetreatedasconfidential.StandardLifeorourreinsurersmay,however,makeabriefreporttotheMedicalInformationBureau,anon-profitmembershiporganizationoflifeandhealthinsurancecompaniesthatoperatesaninformationexchangeonbehalfofitsmembers.Ifyouapplyforlife,criticalillnessorhealthinsurancecoverageorsubmitaclaimforbenefitstoacompany,whichisamemberoftheBureau,theBureauwill,uponrequest,supplythatcompanywiththeinformationinitsfile.TheMedicalInformationBureauwillalsoarrangetorelease,atyourrequest,anyinformationitmayhaveinyourfile.Ifyouquestiontheaccuracyoftheinformation,youmaycontacttheBureauandaskforacorrection.TheaddressoftheBureau’sinformationofficeis: MedicalInformationBureau 330UniversityAvenue,Suite501 Toronto,ONM5G1R7 Telephone:416-597-0590StandardLife,oritsreinsurers,mayalsoreleaseinformationinyourfiletootherlifeinsurancecompaniestowhomyoumayapplyforlifeorhealthinsurance,ortowhomaclaimforbenefitsmaybesubmitted.

Instructiontorepresentative:IF:• ALLproposedinsuredsareolderthan15daysandyoungerthanage66;and • ALLproposedinsuredsanswered“no”toallpartsofquestions1to4oftheTIAInsurabilityQuestions(E4,page7);and • forEACHproposedinsured,thetotalamountoflifeinsuranceappliedforislessthan$3,000,001;thendetachthisAgreementandgiveittotheowner.Regardlessofwhetheranypremiumhasbeencollectedwiththeapplication,thereisnoTemporaryInsuranceAgreementiftheconditionsabovearenotmet.

H1 • Conditional Insurance Agreement For Critical Illness

H2 • Temporary Insurance Agreement (TIA) For Life Insurance

H3 • Disclosure Notice MIB (Medical Information Bureau) – To be detached and given to the owner in all cases

ApplicationNumber:

5071H-01-2010

5071H-01-2010

5071H-01-2010

ApplicationNumber:

ApplicationNumber:

Page13

Page13

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Notice to proposed life insured(s) and policyowner(s) regarding investigative consumer reportsIntheroutineprocessingofapplicationsforinsurancealllifeinsurancecompanies,includingStandardLife,mayobtainpersonalinvestigationorconsumerreportscontainingpersonalinformationabouttheproposedinsured(s)andyoumaybecontactedinthisregard.

Notice to proposed life insured(s) and policyowner(s) regarding files and personal informationToensuretheconfidentialityofthepersonalinformationheldconcerningyou,StandardLifewillestablishafilefortheowner(s)andeachproposedlifeinsured,forthepurposeofprovidingyouwithinsuranceandotherfinancialservices.Thisfilewillcontaininformationconcerningyourapplicationforinsuranceaswellasinformationconcerninganyinsuranceclaim.Onlyemployeesormandatorieswhowillberesponsibleforunderwriting,administration,investigation,servicingandforclaimspurposes,oranyotherpersonwhomyouauthorize,willhaveaccesstothisfile.Yourfilewillbekeptinthecompany’soffices.Youareentitledtoconsultthepersonalinformationcontainedinthisfile,andhaveanyinaccuraciesrectifiedbysendingawrittenrequestto: Standard Life Attn:Manager,CustomerRelationsandOmbudsman 1245SherbrookeStreetWest, Montréal,QuébecH3G1G3

Notice to proposed life insured(s) and policyowner(s)Thetransactionrepresentedbythisapplicationisbetweentheapplicant(s)andStandardLife.TheAgent/AgencysolicitingthisapplicationisanindependentcontractorandwillreceivecompensationfromStandardLifeuponcompletionofthistransaction.Asaresultofthisapplication,theAgent/Agencymaybeeligiblefornon-monetarybenefitsdependingonthevolumeofbusinessthats/heplaceswiththecompanyduringagiventimeperiod.Theapplicant(s)is(are)notobligedtotransactanyotherbusinesswithStandardLifeasaconditionofthistransaction.

TheConditionalInsuranceAgreementwillendonthedatethepolicyappliedforcomesintoforce.Undernocircumstanceswillthisinsurancegobeyond60daysfromtheeffective date.TheamountofCriticalIllnessInsuranceforaproposedinsuredunderthisAgreementislimitedtothelesserof:• thetotalamountofcriticalillnessinsuranceappliedforonthelifeoftheproposedinsured;and• $500,000lessanyothercriticalillnessbenefitspayablebyStandardLifefortheproposedinsured.Ifanyoftheproposedinsuredsisdiagnosedwithcancer,thennopaymentwillbemadeunderthisAgreement.Ifanyoftheproposedinsuredsdieswithin30daysofthediagnosisofadefinedcriticalillness,thennopaymentwillbemadeunderthisAgreement.Ifanyoftheproposedinsuredsisyoungerthan31daysorisolderthanage65,thennopaymentwillbemadeunderthisAgreement.

Date DD/MM/YYYY Representative Name Insured’s Name Sum Insured

$ / /

Date DD/MM/YYYY Representative Name Insured’s Name Sum Insured

$ / /

ExpiryoftemporaryinsurancecoverageIfweaccepttheapplicationasis,thenthisTIAendsontheeffectivedateofthepolicy.Ifwedonotaccepttheapplicationasis,thentheTIAwillendonthedateyourrepresentativeisinformedthatanycoveragehasbeendeclinedornotacceptedasappliedfor.Undernocircumstanceswillthisinsurancegobeyond60days.

1. Haveyoueverhadanapplicationforlife,health,criticalillnessordisabilityinsurance,reinstatementorchangeeither:rated,declined,postponed,modified,ornotproceededwith?

2. Haveyouwithinthepast90days,otherthanfornormalchildbirth,beenadmittedoradvisedtobeadmittedtoahospitalorothermedicalfacilityorhaveyouhadanysurgeryperformedorrecommended?

3. Haveyouinthepast5yearseverhad,beentoldyoumayhaveorbeenadvisedtohavetestsfor:cancer,drugoralcoholabuse,heartorcirculationproblemssuchasstroke,highbloodpressure,chestpain,unexplainedinfections,orhaveyoueverhad,beentoldyoumayhave,beenadvisedtohavetestsfororreceivedinformationindicatingpossibleexposuretoAIDS(HIV)?

4. HaveyouanyintentiontoresideortraveloutsideofNorthAmericaorWesternEuropewithinthenextyear?

Conditional Insurance Agreement For Critical Illness (continued)

Temporary Insurance Agreement (TIA) For Life Insurance (continued)

www.standardlife.ca

TheStandardLifeAssuranceCompanyofCanada

5071H-01-2010

Protection Solutions

Medical and lifestyle supplement

(also known as the Non-Medical)

Life Insurance and Critical Illness insurance

• Ifthissupplementisnotused,pleasedetachanddiscard.

• Quebeconly:theinformationrecordedonthissupplementmustbekeptseparatefromtheLifeInsuranceApplication. Detachbeforecompletionandsubmitwiththeapplication.


Mr Mrs Miss Ms Other: Mr Mrs Miss Ms Other:

First name and initial First name and initial

Last name Last name

Date of birth (DD/MM/YYYY) Date of birth (DD/MM/YYYY)

InstructionsLife Insurance

•Adults:Completeallsectionsexcept1B.1,1B.2,and1C.

•Children:Completeallsectionsexcept1C.

Critical Illness

•Adults:Completeallsectionsexcept1B.1,1B.2,and1C.

•Children:Completeallsectionsexcept1C.

CPR & ECPR

•ChildProtectionRiderandEnhancedChildProtectionRider:Completesection1Conly.

5071H-01-2010

ApplicationNumber:

Page1

Nameofdoctor

Address

TelephoneNumber Datelastseen(DD/MM/YYYY)

Reason

Resultsincludingrecommendedtreatmentorreferral

Nameofdoctor

Address

TelephoneNumber Datelastseen(DD/MM/YYYY)

Reason

Resultsincludingrecommendedtreatmentorreferral

1A • Personal HistoryCompleteforeachinsuredapplyingforlifeand/orcriticalillnesscoverage.

Indicatethenameandaddress ofyourpersonalphysician,thereasonanddatelastseen,andtheresultsincludinganyrecommendedtreatmentorreferral.

1B • Family HistoryCompletethissectionforeachinsuredapplyingforlifeand/orcriticalillnesscoverage.ItisnotrequiredforchildrenapplyingforCPR(Children’sProtectionRider)orECPR(EnhancedChildren’sProtectionRider).

Circleallapplicabledisorders.

INSTRUCTIONS: Refer to the previous page.

/ / / /


Proposed Insured 1 Mother Father Brother(s) Sister(s)

Age Age Age Age Age Age Age Age at Death Diagnosed at Death Diagnosed at Death Diagnosed at Death Diagnosed

a. Indicatenumberofbrothersandsistersb. Indicatestateofhealthiflivingofeachfamilymemberc. Indicatehowmanyfamilymembersandtheageat

whichanyfamilymemberhasbeendiagnosedwithand/ordiedfromanyofthefollowing:

DiabetesStrokeBrainaneurysmMotorNeuroneDiseasesuchasALS(Amyotrophic lateralsclerosisi.e.ALSorLouGehrig’sdisease)MultipleSclerosisAlzheimer’s DiseaseParkinson’sDiseaseHuntington’schoreaPolycystickidneyOtherKidneydisorderHyperlipidemiaor“highcholesterol”,highbloodpressureHeartattack,anginaAnyotherheartorcirculatoryproblemColonpolypsCanceroranytumor (specifytypeandwhethermalignantorbenign)Other:

Proposed Insured 2 Mother Father Brother(s) Sister(s)

Age Age Age Age Age Age Age Age at Death Diagnosed at Death Diagnosed at Death Diagnosed at Death Diagnosed

a. Indicatenumberofbrothersandsistersb. Indicatestateofhealthiflivingofeachfamilymemberc. Indicatehowmanyfamilymembersandtheageat

whichanyfamilymemberhasbeendiagnosedwithand/ordiedfromanyofthefollowing:

DiabetesStrokeBrainaneurysmMotorNeuroneDiseasesuchasALS(Amyotrophic lateralsclerosisi.e.ALSorLouGehrig’sdisease)

MultipleSclerosis

Alzheimer’s Disease

Parkinson’sDiseaseHuntington’schoreaPolycystickidneyOtherKidneydisorderHyperlipidemia,“highcholesterol”,highbloodpressureHeartattack,anginaAnyotherheartorcirculatoryproblemColonpolyps

Canceroranytumor (specifytypeandwhethermalignantorbenign)

Other:

– – – –

1 – Medical History

5071H-01-2010

ApplicationNumber:

Page2

Proposed Child 1 Proposed Child 2ft in. cm ft in. cm

Yes Gain No Loss

lbs kg

Yes Gain No Loss

lbs kg

lbs kg lbs kg

1B.1 • Children’s Medical History for critical illness coverageCompleteforallchildrenapplyingforanycriticalillnesscoverage.

1B.2

1C • Children’s Personal History for CPR and ECPR onlyCompletethissectiononlyforchildrenapplyingforLifeCPR(Children’sProtectionRider)orECPR(EnhancedChildren’sProtectionRider).Do not complete this section for critical illness coverage.

Proposed Child 2 - Age Age Age family member Condition at Onset if Living at Death Cause of Death

Grandmother(paternal)

Grandfather(paternal)

Grandmother(maternal)

Grandfather(maternal)

1. Wasanygrandparentdiagnosedwithdiabetes,heartdisease,Huntington’schorea,polycystickidneys,cancer,strokeorAlzheimer’sdisease? Ifyes,complete1B.2infull.

2. Hasthechildbeendiagnosedwithorhaveanysymptomsofanyofthefollowingconditions:

a. developmentalretardation,orcysticfibrosis b. neurologicalimpairmentincludingattention

deficitdisorder,autism,cerebralpalsy,hyperactivity,motorneuronedisease,musculardystrophy

3. Ifthechild’sageiscurrentlylessthan1yearold,wasthebirthprematurebymorethan4weeks?

4. IsthereCriticalIllnesscoverageonbothparents?Ifyes,howmuch?Ifno,pleaseexplaininSection3Additional Medical & Personal History Details.

Proposed Child 1 - Age Age Age family member Condition at Onset if Living at Death Cause of Death

Grandmother(paternal)

Grandfather(paternal)

Grandmother(maternal)

Grandfather(maternal)

Yes No Yes No

Yes No Yes No Yes No Yes No Yes No Yes No

2. Isanychildcurrentlyundertreatment bymedicationorothermeans?

3. Hasanychildeverhadsurgeryoranyspecializedtest,orisanysurgery,testorinvestigationplanned?

4. Doesanychildtobecoveredhaveorhadanycongenitalheartdisease,hemophilia,physicalhandicapsincludingblindnessordeafness,mentalimpairmentincludingautism,cerebralpalsy,developmentaldelayincludingDown’sSyndrome?

5. DoanyparentsorsiblingshaveanyinheriteddiseasessuchasHuntington’sChoreaorPolycysticKidneyDisorder?Indicatenameofattendingphysicianincludingdate,reasonlastseenaswellasresults.

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

If you answered yes to any of the questions in Section 1C Children’s Personal History for CPR and ECPR, also complete questions in Sections 1A, 1B, 1E, 1F, 1G.

1. Height

Weight

Changeofweightinthelast12months

Reasonforchangeinweight

Proposed Child 1 Proposed Child 2

5071H-01-2010

ApplicationNumber:

Page3



Proposed Insured 1 Proposed Insured 2ft in. cm ft in. cm

Yes Gain No Loss

lbs kg

Yes Gain No Loss

lbs kg

lbs kg lbs kg

1D • Build: What is your current height and weight?Completeforeachinsured.

1E • Are youCompleteforeachinsuredapplyingforlifeand/orcriticalillnesscoverage.

CheckYESorNO,andcircleallapplicable(affirmative)situations/conditions/responsesandprovidedetailsforallYESanswersinSectionAdditional Details below.

Additional Details

1F • Have you ever had any known indication of or been advised to seek testing, treatment or advice for any disorder of the: Completeforeachinsuredapplyingforlifeand/orcriticalillnesscoverage.

CheckYESorNO,andcircleallapplicable(affirmative)situations/conditions/responsesandprovidedetailsforallYESanswersinSection3Additional Medical & Personal History Details.

Height

Weight

Changeofweightinthelast12months

Reasonforchangeinweight

a. brainornervoussystemsuchas:dizzinessorfaintingspells,convulsions,epilepsy,headinjury,persistentheadaches,nervousbreakdown,depression,suicideattempt,suicidalthoughts,burnout,eatingdisorder,paralysis,“tingling”,numbness,MultipleSclerosis,MotorNeuroneDiseasesuchasAmyotrophicLateralSclerosis(ALS),slurredspeech,tremor,Parkinson’sdiseaseormemoryloss? Yes No Yes No

b. eyes,ears,noseorthroat? Yes No Yes No

c. lungsorrespiratorysystemsuchas:shortnessofbreath,persistentcough,chronicbronchitis,emphysema,asthma,pleurisy,tuberculosisorsleepapnea? Yes No Yes No

d. heart,arteriesorotherpartsofthecirculatorysystemsuchas:chestpain,angina,palpitations,highbloodpressure,rheumaticfever,heartmurmur,heartattack,stroke,transientischemicattack(TIA),highcholesterol? Yes No Yes No

e. gastrointestinalsystemsuchas:ulcer,colitis,gallstones,hepatitisincludingcarrierstate,jaundiceorotherdisorderoftheliver,pancreas,stomach,bowelorrectum? Yes No Yes No

f. genitalorurinarysystemsuchas:sugar,protein,albumin,pusorbloodintheurine,sexually-transmitteddisease,kidneystoneorotherdisorderofthekidney,bladder,prostate,breastorgenitalorgans? Yes No Yes No

g. glandsincludingbutnotlimitedto:diabetes,thyroidorotherglandulardisorders,swollenglandsorlymphnodes? Yes No Yes No

h. joints,bones,musclesorlimbssuchas:arthritis,rheumatism,gout,backtroubleand/ordiscdisease? Yes No Yes No

i. bloodincludinganemia,leukemiaorhemophilia? Yes No Yes No

j. immunesystemincludinganyunexplainedinfections? Yes No Yes No

a. presentlytakinganyprescribedornon-prescribedmedicationorhaveyoubeenrecommendedtofollowanytreatmentortoseeanothermedicalprofessional? Yes No Yes No

b. awareofanysymptomsorcomplaintsforwhichyouhavenotyetconsultedaphysicianorreceivedtreatment?Ifyes,pleaseprovide details Yes No Yes No

c. presentlyawaitingamedicalconsultationoranytestresults? Ifyes,pleaseprovidedetails Yes No Yes No

5071H-01-2010

ApplicationNumber:

Page4




Proposed Insured 1 Proposed Insured 21G • Have you Completeforeachinsuredapplyingforlifeand/orcriticalillnesscoverage.

CheckYESorNO,andcircleallapplicable(affirmative)situations/conditions/responses and provide details forallYESanswersinSection3Additional Medical & Personal History Details.

2A • Driving HistoryCompleteforeachinsuredage16andoverapplyingforlifeand/orcriticalillnesscoverage.

2B • Have youCompleteforeachinsuredage16andoverapplyingforlifeand/orcriticalillnesscoverage.

Ifinsuredsareunderage16,completequestionsa,b,conly.

CheckYESorNO,andcircleallapplicable(affirmative)situations/conditions/responses and provide details forallYESanswersinSection3Additional Medical & Personal History Details.

2C • Do you presently use alcoholic beverages? Completeforeachinsuredage16andoverapplyingforlifeand/orcriticalillnesscoverage.

Yes No Yes No

Yes No Yes No

a. Inthepast5yearshaveyouhadyourlicensesuspended,beenconvictedoforpleadedguiltytoanymovingviolations,ordoyoupossiblyhaveanysuchchargesorconvictionspending?Ifso,pleaseprovidedetailsinSection3Additional Medical & Personal History Details,includingtypesofoffences,dates,speedsinvolved,aswellasdriver’slicenseNo.

b. Withinthepast5years,haveyourefusedabreathalyser,beenconvictedoforpleadedguiltytodrivingwhileimpaired,ordoyoudoyoupossiblyhaveanysuchchargesorconvictionspending?Ifso,pleaseprovidedetailsinSection3 Additional Medical & Personal History Detailsaswellasdriver’slicenseNo.

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

a. everhadcancer,anycyst,tumor,lump,orskinlesion?b. withinthepast5years,hadorbeenrecommendedtohaveany

electrocardiograms,bloodtests,X-Raysorothertests?c. withinthepast5years,consultedaphysiciannotmentionedabove

orbeenapatientinahospitalorothermedicalfacility?d. hadanyseriousillness,surgicaloperation,accidentorinjurynot

mentionedabove?e. everusedanyillegaldrugssuchasnarcotics,amphetamines,

barbiturates,cocaine,heroin,LSD,ecstasy,orothersimilaragents? Ifyes,completeadrug-usequestionnaire(2148).

f. everdecidedtoorbeenadvisedtoreduceyourconsumptionofalcoholordrugsortoseektreatmentorcounsellingbecauseoftheuseofalcoholordrugs?Ifyes,completeadrug-usequestionnaire(2148)and/oranalcohol-usequestionnaire(2149).

g. everusedanyillegaldrugssuchasnarcotics,amphetamines,barbiturates,cocaine,heroin,LSD,ecstasy,crystalmethorothersimilaragents?Ifyes,completeadrug-usequestionnaire(2148).

h. had,beentoldyoumayhave,orbeenadvisedtohavetestsfor:AIDS(HIV),orhaveyoureceivedinformationindicatingpossibleexposuretotheAIDS(HIV)virus?

i. anysymptomsnotyetinvestigatedorarethereanyinvestigationsortestspending?

j. withinthepast90daysapartfromnormalchildbirth,beenadmittedoradvisedtobeadmittedtoahospitalorothermedicalfacilityorhaveyouhadanysurgeryperformedorrecommended?

k. everbeenoffworkformorethan2consecutiveweeksduetoanillness,disabilityorinjury?

L. everhadanyillnessorinjurynotindicatedabove?

Wine(4oz) Spirits(2oz) Beer(8oz)



Daily

Weekly

Monthly

Yes (completebelow) NoWine(4oz) Spirits(2oz) Beer(8oz)



Daily

Weekly

Monthly

Yes (completebelow) No

a. everhadanapplicationforlife,criticalillness,healthordisabilityinsurance,reinstatementorchangeeither:rated,declined,postponed,modified,notproceededwith?

b. withinthepasttwoyearstravelledoutsideofNorthAmericaorWesternEurope?Ifyes,completeForeignTravelandResidencequestionnaireNo.3965.

c. anyintentiontoresideortraveloutsideofNorthAmericaorWesternEurope?Ifyes,completeForeignTravelandResidencequestionnaireNo.3965.

d. duringthepast2yearsparticipatedinordoyouintendtoparticipateinhazardoussportssuchasscubadiving,parachuting,motorracing,hang-gliding,bungeejumping,etc.Ifyes,completehazardousactivitiesquestionnaireNo.659.

e. pilotedanaircraftwithinthepasttwoyearsordoyouintendtodosointhefuture?Ifyes,completehazardousactivitiesquestionnaireNo.659.

f. everbeenconvictedoforpleadedguiltytoanycriminaloffencesor anysuchchargespending(otherthanrelatedtodriving)?

2 – Personal History

5071H-01-2010

ApplicationNumber:

Page5

Foradultsandchildrenincludenamesofalldoctors,datesofconsultations,resultsofalltestsandanytreatmentsrecommended.

Minors:AsignatureisrequiredbyallProposedInsuredsage14andoverintheprovinceofQuebecandage16andoverinallotherprovinces.

Indicatesectionandnumber (i.e.1G)

Indicatesectionandnumber (i.e.1G)


ProvinceofSignature this dayof ,20Proposed Insured 1 Proposed Insured 2

Proposed Insured (minor) Proposed Insured (minor)

Consenting Parent/Guardian (ifjuvenileApplicationoranychildren’sRider) Owner(onlyrequiredifdifferentthanProposedInsured1or2)

Ideclarethattheforegoingstatementsaretrue,completeandcorrectlyrecordedandshallformpartoftheapplicationforlifeand/orcriticalillnessinsurancewithStandardLife.Forthepurposeofevaluatingtheriskundertheapplicationforlifeand/orcriticalillnessinsurancewhichhasbeenmadetoStandardLifeorforanyclaimspurposes,Iauthorizeanylicensedphysician,medicalpractitioner,hospital,clinicorothermedicallyrelatedfacility,insurancecompany,MedicalInformationBureau,orotherorganization,institutionorpersontogiveanyinformationregardingmetoStandardLifeoritsreinsurers.Aphotocopyofthisauthorizationshallbeasvalidasthe original.

3 – Additional Medical & Personal History Details

4 – Signatures

comprehensive application form -...

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