Mortgage Application Package – Readvance/Refinance
Table of Contents:
1. London Life Mortgage Information Sheet LL3626
2. Mortgage Acknowledgement LL305
3. Appendix to Mortgage Application Pre-Authorization Debit (PAD) agreement LL300
4. London Life Mortgage Life Insurance Application LL4760
5. London Life Mortgage Default Insurance Disclosure LL3808
Other Forms/Documents (if applicable):
1. Mortgage Submission Checklist (08/2011)
2. DSC Calculator (for rentals)
3. Third Party Determination Record (For Mortgage Accounts) LL295
4. First Canadian Title Forms (applicable to your Province)
5. Mortgage Appraisal Acknowledgement / Authorization (if applicable)
6. Request for Funds RAD (Readvance only)
LL3626 (05/2011-P)
Date MM / DD / YYYY
Select one New client Pre-approved client Rate hold client Expert application #
Application type Approval Pre-approval Application purpose Purchase Refinance Other
Purchase & improvements Switch/transfer (high ratio only)
Applicant information
Mr Ms Mrs Miss Dr Other Birth date
Name First Middle Last MM / DD / YYYY
Social insurance number Marital status Work phone Ext.
( )
Fax Ext. Cell Email
( ) ( )
Contact method Citizenship Staff of lender Employee #
Canadian Other specify No Yes
Co-applicant information
Mr Ms Mrs Miss Dr Other Birth date
Name First Middle Last MM / DD / YYYY
Social insurance number Marital status Work phone Ext.
( )
Fax Ext. Cell Email
( ) ( )
Contact method Citizenship Staff of lender Employee #
Canadian Other specify No Yes
Home phone Number of dependants Preferred language Existing client Client # First time buyer Relationship to Primary applicant
( ) English French No Yes No Yes
Applicant identity
Identification type Identification country/place of issuance Identification #
Co-applicant identity
Identification type Identification country/place of issuance Identification #
Applicant current address
Address City Province Postal code
Time at residence Status Rent
YYYY / MM
If at current address less than 3 years, provide previous address
Address City Province Postal code How long
Co-applicant current address
Address Same as applicant or City Province Postal code
Time at residence Status Rent
YYYY / MM Own Live with parents Rent Other specify $
If at current address less than 3 years, provide previous address
Address City Province Postal code How long
Mailing address
Address Same as applicant Same as property address or City Province Postal code
Page 1 of 3
London Life Mortgage Information Sheet
For Mortgage Planning Specialist use only
Applicant employment
Employer’s name
Status Type Country
Full time Part time Seasonal Canada Other specify
Address City Province Postal code
Self- employed Company type Operating as
Gross revenue Job title Occupation/position
$
Industry sector Income type Income period Time at job Years in industry Income amount YYYY / MM YYYY / MM $
If at current employer less than 3 years, provide previous employer
Employer’s name City Province Postal code How long
Co-applicant employment
Employer’s name
Status Type Country
Full time Part time Seasonal Canada Other specify
Address City Province Postal code
Self- employed Company type Operating as
Gross revenue Job title Occupation/position
$
Industry sector Income type Income period Time at job Years in industry Income amount YYYY / MM YYYY / MM $
If at current employer less than 3 years, provide previous employer
Employer’s name City Province Postal code How long
Other income
Interest Child support Pension/disability Alimony Income period Income amount$
Financial information - Attach separate page if necessary
AssetsType Description Value Down payment
$ $ $ $ $ $ $ $ $ $ $ $ Liabilities
Type Limit Balance Payment Payoff
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $
Page 3 of 3
Properties owned - Attach separate page if necessary
Occupancy (select one) Owner occupied Owner occupied & rental Rental Second home
Address City Province Postal code
Property value Original value Purchase date Annual taxes Total monthly condo fees Fees include heat Monthly heating
$ $ MM / DD / YYYY $ $ No Yes $
Rental income per month Hydro per month Other per month
Management per month Insurance per month Repairs per month Interest per month
Mortgage information - Required for all properties owned
Mortgage type Balance Payment Payment frequency Maturity date
$ $
Rate type Term type Mortgage holder Payoff Loan type
Mortgage interest rate Mortgage # Original mortgage amount Insurance account # Insured Insurer
% $ No Yes
Subject property information
Occupancy (select one) Owner occupied Owner occupied & rental Rental Second home
Address City Province Postal code
Lot Block Conc./Township (tax authority) MLS listing
No Yes
Construction type Housing type Tenure Living space Lot size
Heat type Water type Style # of units Age Garage size Garage type Sewage info
Annual taxes Tax year Paid by Total condo fees Fees include heat Heating
$ per year Borrower Lender $ per month No Yes $ per month
Purchase price Estimated value Appraisal value
$ $ $
Down payment - Attach separate sheet if required
Source Description Amount
$ $
Mortgage information
Closing Financing waiver Purpose for refinance MM / DD / YYYY MM / DD / YYYY
Improvements Improvement value 1st mortgage
description $ $
Mortgage request details
Product/term Interest adjustment date First payment date Progress advance
MM / DD / YYYY MM / DD / YYYY No Yes Insurance premium included in Mortgage Mortgage insurance provider Mortgage insurance product
No Yes
Payment frequency Amortization MM / YYYY
Register mortgage for $ Increase PI payment to $
Participants
Contact type
Service branch/Region office
Referral source (Consultant/Advisor) Name Number
Solicitor name phone fax email
Address City Province Postal code
This Mortgage Information Sheet may be completed when clients wish to obtain a mortgage from London Life, and the information herein shall be incorporated into the Mortgage Application and shall be considered to be governed by the Mortgage Application as described in the Mortgage Acknowledgement.
Mortgage Acknowledgement
Deal N
o. ___________________________
Instructions
This Mortgage Acknowledgement (“Acknowledgement”) must be reviewed by the Applicant(s) and/or Guarantor(s) after the Mortgage Application is
completed. Applicants and Guarantors must review each of the sections below, initial where indicated and then attach their signatures at the end of this
Acknowledgement.
Acknowledgement and Consent
In connection with my request to obtain a mortgage from London Life (as defined below), I hereby acknowledge that a Mortgage Application form (the
“Application”) has been completed on my behalf, using information (“Personal Information”) provided by me. Personal Information that I have provided
to London Life includes but is not limited to my name, address, contact information, social insurance number, employment information, information about
properties I own or plan to purchase with the proceeds of the mortgage, and financial information.
I acknowledge that I have reviewed this Mortgage Acknowledgement in its entirety as evidenced by my initials and my signature as set out herein.
Use, Collection and Disclosure of Personal Information
I hereby agree to the use, collection and disclosure of Personal Information about me as follows:
Use
• I understand that London Life (as described under Certifications and Signatures below) needs to collect Personal Information about me to use for:
• identifying me;
• verifying the information concerning my eligibility for the products and services being applied for;
• establishing and maintaining its relationship with me, including servicing my account;
• meeting my needs for ongoing products and services;
• protecting my interests and those of London Life from error and fraud;
• allowing persons or third parties working with London Life to service my account; and
• complying with legal, security, processing, and regulatory requirements.
• I authorize London Life to use my social insurance number and business numbers for tax reporting, record keeping and identification purposes.
Collection
• I authorize London Life to collect Personal Information about me from financial institutions, credit grantors, credit bureaus, reporting agencies, my
employer, persons with whom I do business and other service providers of London Life for the uses stated above.
• I understand London Life does not allow Personal Information to be sold, rented or traded.
Disclosure
• I authorize London Life to disclose to or exchange my Personal Information with its affiliates, subsidiaries, Advisors, financial institutions, credit
grantors, credit bureaus and reporting agencies, my employer, its service and funding providers, its suppliers, and government authorities or self
regulatory organizations for the uses stated above.
• I understand that further to this Acknowledgement, London Life establishes a confidential file that contains Personal Information concerning me,
and that the file is kept in the offices of London Life or of third-parties acting on its behalf. I further understand that rights of access to Personal
Information in the file are limited to its staff or persons authorized by it who require it to perform their duties, to me and persons authorized by me,
and, as Personal Information may be used, collected, or disclosed in or from Canada or elsewhere, access may be had by persons authorized by the
laws of Canada or elsewhere, as applicable. My rights of access and correction of any inaccuracies, or to make a privacy complaint or withdraw any
Personal Information authorization or consent given, may be exercised by e-mailing the Chief Compliance Officer at:
[email protected], or by writing to either of the London Life addresses shown within this Acknowledgement.
• I authorize London Life to keep my Personal Information for as long as it is needed for the uses stated above, even if I am no longer a client of
London Life.
• I acknowledge that I can contact London Life using the process described above to withdraw my consent to the use, collection and disclosure of
Personal Information. However, I understand if I withdraw my consent to the use, collection and disclosure of Personal Information, then London Life
may be unable to continue servicing my account, maintain its relationship with me, or renew my mortgage financing, and that I may have to obtain
mortgage financing elsewhere at the end of my mortgage term.
Mortgage Acknowledgement
Deal N
o. ___________________________
Page 2 of 4 LL305 (11/2010-PW)
Disclosure to Co-borrowers
•
Where more than one Applicant is named in the Application (“Co-borrowers”), we understand that we have the right to receive all disclosure
(“Mortgage Disclosure”) separately but that we may elect to receive it jointly. Accordingly, we hereby direct (“Direction”) that all Mortgage Disclosure
be sent jointly to us at the address designated (“Designated Address”) in the section of the Application headed “Property Address” (“Primary mailing
address”) if the “Joint disclosure” line below is checked. If the “Joint disclosure” line is not checked, we understand that we will receive all Mortgage
Disclosure separately at the addresses we have listed in the Application, except any offers to renew any mortgage loan provided as a result of the
Application, which will be sent only to the Primary mailing address.
•
We understand that we can change our Direction at any time and elect to receive Mortgage Disclosure separately from our Co-borrower
at an address other than the Designated Address by providing written notice to London Life at either of the addresses shown within this
Acknowledgement.
•
We acknowledge that (i) this Direction applies to all Mortgage Disclosure relating to the Application, any mortgage loan provided as a result of the
Application and any renewal of any such mortgage loan, unless superseded by a subsequent Direction by a Co-borrower to receive Mortgage
disclosure separately, as provided above (ii) any subsequent update we provide to London Life as to our Designated address shall not affect this
Direction unless that update constitutes a revised Direction by a Co-borrower to receive Mortgage Disclosure separately and (iii) notwithstanding
any Direction provided by a Co-borrower to receive Mortgage disclosure separately, all offers to renew any mortgage provided as a result of the
Application will be sent only to the Designated address.
•
For the purpose of this Direction, “Mortgage disclosure”, includes, but is not limited to, annual statements, changes of mortgage terms and renewal
confirmations.
Joint disclosure - check here to have all Mortgage disclosure sent jointly to the Primary mailing address.
Applicant(s) initials
____________ _____________
Guarantor(s) initials _____________ ____________
Things to Know
With respect to my Application for a mortgage from London Life, I hereby acknowledge and/or agree to the following:
• For a closed fixed rate term mortgage, I understand that, once advanced, any subsequent changes in interest rates offered by London Life will not
have any effect on my interest rate or payment amount for the duration of the term that I selected.
• For an adjustable rate term mortgage, I understand that the interest rate and payment amount will be adjusted on each interest and payment reset
date to reflect the following:
• changes to the mortgage prime rate as set and published by London Life from time to time (our “Mortgage Prime Rate”), or
• any changes to the applicable base rate as specified in any loan approval (the “Loan Approval”) letter subsequently issued by London Life.
• For a variable rate term mortgage, I understand that the interest rate will change each time there is a change in our Mortgage Prime Rate resulting in
a change in the amount of my payment allocated to interest, which may negatively impact the amortization period of my mortgage.
• For all types of mortgages, I understand and agree that neither this Acknowledgement nor my Application constitutes an approval by London Life to
grant a mortgage to me. I further understand that the terms and conditions of any such approval shall be set out in the Loan Approval letter (to be
issued by London Life at a later date), including but not limited to the following:
• Renewal interest rates will be subject to whatever mortgage rates are set by London Life at the time of my renewal.
• Any payments made by me, in whole or in part, that are in excess of the Prepayment Privilege amounts set out in the Loan Approval letter will
be subject to the prepayment charges of either (a) the greater of three months interest on the excess amount being prepaid; or (b) interest for
the remainder of the term on the excess amount being prepaid calculated using an interest rate differential between my contract interest rate
and the current reinvestment rate of London Life.
• Fees may be charged for mortgage renewal, discharge, transfer, assignment, dishonored payments, collection and enforcement activities.
I acknowledge that any subsequent granting of the mortgage by London Life, or approval for insurance by its service providers, is not to be construed or
relied upon by the Applicant(s) and any Guarantor(s) as representing a confirmation of the ability of any of the Applicant(s) and any Guarantor(s) to pay
the mortgage. I further acknowledge that London Life, and its service providers, provide no opinion, nor any warranty or guarantee (express or implied),
with respect to the property being secured by the mortgage, including its current or future value, condition, marketability, or suitability for my needs,
whether or not appraisals or inspections were carried out by me or on my behalf.
Mortgage Acknowledgement
Deal N
o. ___________________________
Authorizations
With respect to my Application for a mortgage, I authorize London Life to share (and obtain) account and credit information with (and from) any and all
credit grantors and credit bureaus as necessary.
Other Liabilities
With respect to my Application for a mortgage and the ability of London Life to assess my suitability for same, I certify that I have not guaranteed or
co-signed any loans, notes, or mortgages on behalf of other persons, that I am not a defendant in any legal actions, that there are presently no legal
judgments against me and that I have not declared bankruptcy at any time, except as indicated in the Application.
Politically Exposed Foreign Person
Canada’s Anti-Money Laundering and Anti-Terrorist Financing legislation requires determination of whether any Applicants are a “politically exposed
foreign person”. A politically exposed foreign person is defined as an individual and/or close relative(s)* who holds or has held one of the following offices
or positions in or on behalf of a foreign country.
1. Member of the executive council of government
6. Head of state or head of government
2. President of a state-owned company or a state-owned bank
7. Head of a government agency
3. Deputy minister or equivalent rank
8. Judge
4. Ambassador or attaché or counsellor of an ambassador
9. Military officer with a rank of general or above
5. Leader or president of a political party represented in a legislature
10. Member of a legislature
*Close relative(s) means spouse, civil union spouse or common-law partner, children/step/adoptive children, siblings/half siblings/step siblings of the
applicant(s), biological/adoptive/step-parent of the applicant/(s), biological/adoptive/step-parent of spouse, civil union spouse or common-law partner.
I certify that I am not (and none of my close relative(s) are) a politically exposed foreign person.
Check here if any Applicant(s) or their close relative(s) are a politically exposed foreign person and complete the following:
Name(s) of any politically exposed foreign person __________________________________________________________________________________
Relationship(s) to Applicant(s) __________________________________________________________________________________________________
Position(s) held (use numbers from above-noted list) ________________________________________________________________________________
Country where position(s) held _________________________________________________________________________________________________
Mortgage Acknowledgement
Deal N
o. ___________________________
Page 4 of 4
Certifications and Signatures
With respect to my Application for a mortgage, I hereby certify and/or acknowledge that:
• The information I have provided in the Application and in this Acknowledgement will be relied upon by London Life, its funding providers, suppliers
and holders of the mortgage in assessing my eligibility for the applied for products and services.
• I am responsible for all legal and/or administrative expenses whether or not the mortgage is approved and subsequent loan is completed.
• I am conducting this transaction on my own behalf and the mortgage will not be used by, or for the benefit of, or on behalf of, a third party.
Check here if the mortgage is for a third party and complete LL295 Third Party Determination Record
• My London Life Mortgage Planning Specialist has reviewed the Application and this Acknowledgement with me and provided recommendations that I
believe appropriately meet my expressed needs.
• “London Life” in this Acknowledgement and in the Application means London Life Insurance Company (and extends to those acting on its behalf, as
applicable) and its successors and assigns.
• Any reference to “I”, “me” or “my” means each Applicant or Guarantor, as applicable, named in the Application and this Acknowledgement.
• I have requested that this document and all documents related thereto be written in the English language only. Les soussignés déclarent qu’ils ont
exigé que ce document ainsi que tous les documents connexes soient rédigés en anglais seulement.
I certify that I have read and understand this entire Acknowledgement, and that the information I have provided in the Application and in this
Acknowledgement is correct to the best of my knowledge and belief.
Applicant name
Signature
Date
YYYY / MM / DDCo-Applicant
Signature
Date
YYYY / MM / DDGuarantor name
Signature
Date
YYYY / MM / DDCo-Guarantor name
Signature
Date
YYYY / MM / DDI have fully reviewed the entire Application and this Acknowledgement form with the Applicant(s) and Guarantor(s) and provided recommendations that I
believe are appropriate to meet their expressed needs.
Specialist name
Signature
Date
YYYY / MM / DDAs at the date of this Acknowledgement, I have viewed and verified the identity of the Applicant(s) and Guarantor(s) through signature and photo
comparisons of two separate pieces of original valid identification, one of which had their photo and signature.
Witness name
Signature
Date
YYYY / MM / DDLondon Life
Outside Québec: Mortgage Operations 447 Portage Avenue Winnipeg, Manitoba R3C 3B6 In Québec: Mortgage Operations2001 University Street, Suite 1900 Montréal, Quebec H3A 2A6 For information, call toll-free 1 888 893-8383, or fax 1 866 686-3996 In Quebec, 1 888 335-4433, or fax 1 866 686-3996 www.londonlife.com
Applicant information
Applicant name Social insurance number
Co-applicant name Social insurance number
PAD information
The regularly scheduled debited amount will be in a sum sufficient to cover the periodic mortgage payments due (covering principal & interest and, if applicable, property taxes) on a monthly basis unless alternate arrangements are specified in the Applicant/Co-applicant acknowledged Loan Approval Letter, or Mortgage Renewal Offer, or other such Applicant/Co-applicant authorized document regarding payment amount and frequency.
Bank account information - a sample personalized void cheque must be attached to this agreement
Financial institution Address
Bank # Transit # Bank account # Chequing Savings
Name of person who owns the bank account, if not the same as the Applicant/Co-applicant (When this situation is applicable, completion and submission of C3377 Third
Party Determination Record is mandatory and signature required as “Other” in Signature section below).
Mr Ms Mrs Miss Dr Other
Name First Middle Last
Terms & conditions - Reference to “I”, “me” or “my” means each individual as named within this Pre-Authorized Debit (PAD) agreement (the “Agreement”)
• I authorize London Life to proceed with the Pre-Authorized Debits (the “Debit(s)”) from the account (the “Account(s)”) indicated above in an amount required to cover theperiodic payments due pertaining to my mortgage payments (principal & interest, property taxes (if applicable)), fees for the administration of my mortgage, as well as any other applicable sums. The periodic payment amount and frequency will be acknowledged by me in the Mortgage Loan or Transfer Approval, or Renewal Agreement, or other such document that I have signed.
• I agree that for the purpose of this Agreement all Pre-Authorized Debits from my Account will be treated as a Personal PAD in accordance with the Canadian Payments Association rules (the “Rules”).
• I warrant and guarantee that all persons whose signatures are required for completing this Agreement to authorize Debits from my Account with the above named financial institution have signed this Agreement, and I authorize and direct such financial institution to deal with the Debit as if it were a written instruction signed by me in accordance with the Rules.
• By signing this Agreement, I hereby waive any pre-notification requirements as specified by sections 15(a) and (b) of the Canadian Payments Association Rule H1 with respect to pre-authorized debits or if I provide instructions to London Life* to modify the terms and conditions of the Debits.
• I undertake to inform London Life in writing of any change on the Account before the due date of the next Debit. To continue Debits without interruption, I understand that London Life requires receipt of any notice of change at least fourteen (14) calendar days before the next Debit date.
• I understand that I am responsible for ensuring that the balance to be paid by Debit is available in my Account, failing which, charges for insufficient funds (NSF cheque) will apply.
• I agree to regularly review my Account information and if I question or disagree with the Debit amount or any Account changes, I will notify London Life within ninety (90) calendar days of the Debit or Account changes. Otherwise, I agree that the Debit or Account changes will be considered to have been properly made.
• The financial institution named above is not required to verify that the Debits have been issued in accordance with the particulars set out in this Agreement.
• 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 Agreement. I may obtain more information on my recourse rights by contacting London Life or by visiting the Canadian Payments Association website at www.cdnpay.ca.
• Cancellation of this Agreement applies only to the method of payment and does not otherwise have any bearing on the contract for goods and services provided by London Life (including my mortgage). I must provide London Life with written notice of cancellation of the Debits at least fourteen (14) calendar days before the next payment date. I may obtain a copy of a cancellation form by visiting http://cdnpay.ca/imis15/pdf/pdfs_news/sample_pad_cancellation_form.pdf or for more information regarding my right to cancel my Debits, I may either visit www.cdnpay.ca or contact London Life. I agree to release London Life of all liability if the cancellation request is not respected, except in the case of gross negligence by London Life.
• I have requested this application form and all other documents relating hereto to be in English. J’exigé que ce formulaire et tous les documents y afférant soient rédigés en anglais.
*London Life Mortgage Operations contact information:
(Outside Québec) 447 Portage Avenue, Winnipeg, Manitoba R3C 3B6 toll-free 1 888-893-8383 fax 1 866 686-3996 or www.londonlife.com (In Québec) 2001 University Street, Suite 1900, Montréal Québec H3A 2A6 toll-free 1 888-335-4433 fax 1 866-686-3996 or www.londonlife.com
Signature(s) - signatures of all Account owners are required for “joint” bank accounts
Applicant X Date YYYY / MM / DD
Appendix to Mortgage application
Pre-Authorized Debit (PAD) agreement
“London Life” refers to London Life Insurance Company (and extends to those acting on its behalf, as applicable).London Life Mortgage
INSTRUCTIONS
Please complete all questions on this application (page 1, 2 & 3) and attach a void cheque. Is this application for pre-approval purposes? (check only if applicable) Yes Referring advisor
Advisor # RO #
Originating office mortgage planning specialist # servicing office
APPLICANT INFORMATION
Where more than one person applies for coverage, the older is the “Applicant”. The younger is the “Co-applicant”. Loan number
(Name) First Middle Last
Birth date YYYY / MM / DD Age
Property Address
Apt / Unit Street Possession date YYYY / MM / DD
City Province Postal code
Home phone number ( ) Work phone number ( )
Current Mailing Address Check if same as property address
Apt / Unit / Box No. Street
City Province Postal code
CO-APPLICANT INFORMATION
(Name) First Middle Last
Birth date YYYY / MM / DD Age
Current Mailing Address Select if same as Applicant’s mailing address
Apt / Unit / Box No. Street
City Province Postal code
CANCELLATION OF INSURANCE
You may cancel your insurance at any time. If you cancel your insurance within 30 days from the Effective Date of Insurance you will receive a full refund of any premiums paid and the insurance coverage will be deemed never to have been in force.
PROTECTING YOUR PERSONAL INFORMATION
At The Great-West Life Assurance Company (Great-West Life), we recognize and respect the importance of privacy. When you apply for coverage, we establish a confidential file that contains your personal information. This file is kept in the offices of Great-West Life or the offices of an organization authorized by
Great-West Life. You may exercise certain rights of access and rectification with respect to the personal information in your file by sending a request in writing to Great-West Life. Great-West Life may use service providers located within or outside Canada. We limit access to personal information in your file to Great-West Life staff or persons authorized by Great-West Life who require it to perform their duties, to persons to whom you have granted access, and to persons authorized by law. Your personal information may be subject to disclosure to those authorized under applicable law within or outside Canada. We collect, use and disclose the personal information to administer the plan, including investigating and assessing claims, and creating and maintaining records concerning our relationship. Great-West Life or its reinsurers may also release information to other life insurance companies to whom you apply for life or health insurance, or to whom you submit a claim for benefits. The company will not, however, reveal to another company the action taken on the basis of your current request for insurance. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service providers), write to Great-West Life’s Chief Compliance Officer at [email protected], or refer to www.greatwestlife.com.
THE APPLICATION
This application consists of the [3] pages within this booklet and such other documents as by written agreement are to form a part of this application.
Mortgage Life Insurance Application - Part 1 of 3
WAIVER OF INSURANCE
I understand the benefits available under this policy and decline to apply for coverage at this time. I am aware.that I can apply at a later date by contacting the Mortgage Servicing Centre at 1-888-893-8383 (or in Quebec, 1-888-335-4433).
MONTHLY INSURANCE PREMIUM RATE
If you are applying for insurance with a co-applicant, select the premium rate that corresponds with the age and smoking status of the OLDER person. Monthly premium rates per $1,000 of insured mortgage loan
Smoker Non-Smoker
Age Single Joint Single Joint
Under 30 $0.11 $0.15 $0.05 $0.07 30 - 34 $0.14 $0.20 $0.07 $0.10 35 - 39 $0.24 $0.34 $0.11 $0.15 40 - 44 $0.38 $0.53 $0.18 $0.25 45 - 49 $0.60 $0.84 $0.29 $0.41 50 - 54 $0.88 $1.23 $0.43 $0.60 55 - 59 $1.12 $1.57 $0.54 $0.76 60 - 64 $1.34 $1.88 $0.63 $0.88
The mortgage balance insured must equal the mortgage balance at time of application, subject to the Maximum coverage amount. Maximum coverage is $500,000. If your present mortgage balance is more than $500,000, your premium will be based on $500,000 and you will be covered for the maximum amount of $500,000.
Mortgage balance $ / $1,000 Sample calculation: An applicant (age 35) non-smoker, $100,000 mortgage balance:$100,000 ÷ 1,000 x .11 = $11.00 monthly rate. Monthly premium rate
(before discount, if
applicable) $
If applicable, Group Discount Plan, deduct 5% from monthly premium rate: (Ex. $11.00 x 5% = $0.55 discount. Monthly premium before sales tax = $10.45). Discounted monthly premium rate before sales tax: $
Monthly premium
rate (min. $5.00) = $ + provincial sales tax, where applicable, such as, 7% (Manitoba), 8% (Ontario) or 9% (Quebec).
DECLARATIONS, AUTHORIZATIONS, ACKNOWLEDGEMENTS AND SIGNATURES
I understand, acknowledge and agree that:
• I hereby voluntarily apply for coverage under London Life Mortgage Life Insurance Policy No. 150594GL underwritten by Great-West Life, subject to all the terms, conditions and provisions of this policy.
• I am eligible to apply for Mortgage Life Insurance only if: I am a Canadian resident; I am between 18 and 64 years of age; and a borrower, co-borrower or a guarantor of a first mortgage loan on a owner occupied dwelling.
• The Effective Date of Insurance is the later of: the date I signed the Application; or the date Great-West Life approves the application; or the date the mortgage loan is advanced. • No insurance coverage will be in effect if I answered “Yes” to any health question; or if the total Life Insurance coverage exceeds $300,000 under the policy. • Benefits are payable solely to London Life (the “Creditor”) to be applied against the insured portion of my outstanding principal balance of the mortgage loan. • All the information shown and all answers and statements made in this application are correct. • Concealment, misrepresentation or a false declaration on this application could cause my insurance to be void. • No benefits are payable if death is a result of a suicide, whether sane or insane within the first two years of the Effective Date of Insurance. • Definitions and details of coverage, claims, limitations and exclusions, and termination of insurance are set out in the Certificate. • I request that this Application and any related documents be drawn up in English. Je demande que la présente proposition et tous les documents s’y rattachant soient rédigés en anglais. • By signing below, I certify that I have read, understood and agree with the contents of the section entitled “Protecting your Personal Information” in this application. • I have met and agreed to all the terms and conditions on all parts of this application.
___________________________________________ ____________________________________________ _________________________
Applicant signature
Co-applicant signature
Date (YYYY/MM/DD)
Mortgage Life Insurance Application - Part 2 of 3
Page 2 of 3 LL4760-8/12 Copy 1 - Insurer Copy Copy 2 - Agent/Distributor Copy Copy 3 - Customer Copy
Health Questionnaire - Part 3 of 3
and Pre-Authorized Debit Agreement
APPLICANT INFORMATION
Where more than one person applies for coverage, the older is the “Applicant”. The younger is the “Co-applicant”.
Servicing office Loan number
(Name) First Middle Last
Birth date YYYY / MM / DD Age
CO-APPLICANT INFORMATION
(Name) First Middle Last
Birth date YYYY / MM / DD Age
HEALTH QUESTIONNAIRE
Applicant
Co-applicant
All Applicants and Co-applicants must complete this section to the best of their knowledge and initial below: Yes No Yes No
(If you are uncertain how to answer a question, answer “yes” and you will be contacted for further information.) 1. Are you under observation or taking treatment for any disorder or do you have any reason to believe
you will require medical or surgical treatment during the current or next year? 2. Have you ever been refused insurance or charged a higher premium?
3. Do you suffer or have you ever suffered from any physical impairment of, or had any indication of heart, lung, kidney or intestinal trouble, cancer, acquired immune deficiency syndrome (AIDS), test results indicating exposure to the AIDS virus (HIV), diabetes or abnormal blood pressure, disease of the nervous system or brain, stroke, alcohol or other substance abuse, convulsions, fainting spells or nervous breakdown, or have you consulted a physician for any of these physical impairments? If you answered “Yes” to any health question or your total life insurance coverage exceeds $300,000 under the policy your application will be sent to Great-West Life for medical underwriting. In this case, Great-West Life will contact you for further information.
I hereby acknowledge that no insurance may be granted prior to approval by Great-West Life.
Initial Initial
NON SMOKER DECLARATION
I hereby declare that I have not smoked any cigarettes during the past 12 months. I recognize that The Great-West Life will rely on the truth of this declaration in issuing this coverage to me, and I acknowledge that if this statement is false, Great-West Life may, at its discretion, void this insurance coverage.
___________________________________________ ____________________________________________ _______________________
Applicant signature
Co-applicant signature
Date (YYYY/MM/DD)
PRE-AUTHORIZED DEBIT (PAD) AGREEMENT (Attach VOID cheque)
I authorize Great-West Life to debit the account referenced on the sample “VOID” cheque attached to this application and as captured below, for all regular recurring premium payments due (including tax, if applicable) with respect to the coverage applied for under Creditor’s Group policy No.150594GL. I understand that the entire insurance premium for all insured persons on the loan(s) will be charged to the designated account which is owned by the Applicant and/or the Co-Applicant. I agree that for the purposes of this PAD Agreement all pre-authorized debits from my account will be treated as Personal.
The premium debit will occur on the 10th day of each month. I hereby waive the right to receive 10 days’ notice of an increase or decrease in the amount of the automatic withdrawal or a change in the date of the withdrawal.
I may revoke my authorization at any time by giving written notice to Great-West Life at the address below at least 10 business days before the next scheduled debit. To obtain a sample cancellation form, or for more information on my right to cancel a PAD Agreement, I may contact my financial institution or visit www.cdnpay.ca. 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 PAD Agreement. To obtain more information on my recourse rights, I may contact my financial institution or visit www.cdnpay.ca.
The Great-West Life Assurance Company Creditor Insurance Auto Pay
330 University Avenue Toronto Ontario M5G 1R8
London Life Mortgage Operations 447 Portage Avenue Winnipeg, Manitoba R3C 3B6 Quebec office: 2001 University Street Suite 1900
Montreal, Quebec H3A 2A6 For information, call toll-free 1-888-893-8383, or fax 1-866-686-3996.
In Québec, 1-888-335-4433, or fax 1-866-686-3996
Mortgages are offered through I.G. Investment Management, Ltd.*. Inquiries will be referred to a Mortgage Planning (Agent) Specialist. *In the Province of
