Application for
your Structured
Settlement
* These instructions are valid as of the date of printing and are subject to change.
Term (Temporary Single Life or Temporary Joint Life only) – Enter
the term in years and months.
Indexation of Annuity Payments – For each annuity, check the
box to select No Indexation or complete the applicable fields (if not completed, No Indexation will be deemed the default option). Only one indexing option (X%, $X or CPI) can be selected for any one annuity.
• Percentage or Dollar Amount – Indicate the annual indexation level as X% or $X.
• Commencement Date (not applicable for CPI indexing) – To indicate the annual indexation date, check the applicable box for Ann. (anniversary) or January 1st or by entering a date
under Other.
• CPI – Complete the following for each annuity where CPI indexing applies:
Partial/Full – Use P or F to indicate partial or full CPI. Immediate/Deferred – Use I or D to indicate immediate or
deferred CPI. For an immediate annuity, only immediate CPI is available. For a deferred annuity, immediate or deferred CPI can be selected.
Joint Life Reduction – For each Joint Life annuity, check the box
to select No Reduction or complete the applicable fields (if not completed, No Reduction will be deemed the default option). • Percentage or Dollar Amount – Indicate the applicable
reduction as X% or $X.
• On Death of Prime or First – Use P or F to indicate whether the annuity will reduce on prime’s death or on first death.
• Time (Before/After gtd. period) – Use B or A to indicate whether the annuity will reduce before or after the end of the guaranteed period.
Lump Sums – Complete the following if lump sum payments
are applicable.
• Measuring Life – Using the applicable number from 1 to 4, indicate the Measuring Life for each lump sum.
• Lump Sum Payment – Indicate the amount of each lump sum payment.
• Life Contingent – Check the box to indicate if the lump sum is payable on a life contingent basis.
• Payment Date – Indicate the lump sum payment date.
Additional information or instructions – Provide any additional
information concerning this application.
6 Declaration and Signatures – The Owner and Joint Owner
(if any) must sign and date the application form. The Insurance Representative must sign to witness the signatures.
8 Insurance Representative Certification – The Insurance
Representative must sign, date and enter the 6-digit representative code issued by Standard Life (e.g., 099999).
Structured Settlement Annuity Direct Deposit Service To have
payments made by direct deposit, complete this slip in full and attach a void specimen cheque.
Quotations - Structured Settlement Annuity quotations are
available from our Wealthcare software. A quotation from Wealthcare must be submitted as part of the documentation to establish a Structured Settlement Annuity.
Top of Form - Indicate whether the Structured Settlement
Annuity Contract is to be issued by The Standard Life Assurance Company of Canada or Standard Life Assurance Limited. Select The Standard Life Assurance Company of Canada when there will not be an assignment of liability. Select Standard Life Assurance Limited when the liability will be assigned to The Standard Life Assurance Company of Canada, and submit a completed Assignment and Assumption Agreement with the application.
Indicate the Owner’s language preference – if not completed, all correspondence will be issued in the language of the application form.
1 Ownership Provide all information for the Owner (Annuitant,
Beneficiary) and the Joint Owner (if any). If available, enter the claim number and on the Attention line, enter the name of the contact.
2 Measuring Life(ves) - Provide all information together with
valid proof of age (copy of a birth or baptismal certificate, etc.) for each Measuring Life. If two or more Measuring Lives have the same address, enter “Same address as Measuring Life No. ___”.
3 Secondary Payee Complete to name a Secondary Payee in the
event of the primary payee’s death.
4 Contract Details In the space provided for Single Premium
and paid on, indicate the amount on which the annuity and/or lump sums are based and the date the premium was submitted to Standard Life.
Measuring Life – Using the applicable number from 1 to 4,
indicate the Measuring Life for each annuity.
Annuity Type – Indicate the annuity type for each annuity –
TC – Term Certain
SL – Single Life
JL – Joint Life
TSL – Temporary Single Life TJL – Temporary Joint Life
Guaranteed Option – Only one of the three guaranteed options can be selected for any one annuity.
• Guaranteed Period (all types) – Indicate in years and months the period for which annuity payments are guaranteed.
• LCR (Single Life only) – Check the box to indicate that the annuity is to be issued on a Life Cash Refund basis.
• IR (Single or Joint Life only) – Check the box to indicate that the annuity is to be issued on an Installment Refund basis.
Annuity Payment – Indicate the annuity payment amount for each annuity.
Frequency – Indicate the annuity payment frequency for each annuity.
M – Monthly Q – Quarterly S – Semi-annually A – Annually
Commencement Date (between 1st and 28th) – Indicate the
annuity payment start date for each annuity.
How to Complete the Application Form*
This form is used to apply for a Structured Settlement Annuity. Please answer all questions clearly and completely. The Owner must initial any modifications. In this application form, Measuring Life means the life proposed for the annuity and/or lump sum payment(s).
Space is provided on each application for 4 Measuring Lives. For a 5th Measuring Life, use an additional application form and submit both
Application for Structured Settlement Annuity
The Standard Life Assurance Company of Canada (Refer to as “Standard Life” hereafter) Standard Life Assurance Limited
If you have selected the Standard Life Assurance Limited box please refer to section 7. Language Preference English French
1 Ownership Owner, Annuitant, (Beneficiary) Joint Owner (if any) Claim No. Claim No. Attention Attention Address Address City City
Province Postal code Province Postal code
2 Measuring Life(ves) (Proof of age must be submitted for each Measuring Life)
Measuring Life (1) Measuring Life (2)
Last name Given name Initial Last name Given name Initial
Address City Address City
Province Postal code Province Postal code
Date of Birth Sex Male Female Date of Birth Sex Male Female
Measuring Life (3) Measuring Life (4)
Last name Given name Initial Last name Given name Initial
Address City Address City
Province Postal code Province Postal code
Date of Birth Sex Male Female Date of Birth Sex Male Female
3 Secondary Payee (Following death of Measuring Life[ves])
Owner Joint Owner Estate of Measuring Life(ves) Other (specify):
Last name Given name Relationship
Note: For annuities with a Life Cash Refund guarantee option, the Death Benefit will be paid to the owner regardless of any other specified Secondary Payee named in this Contract.
(1-4)
4 Contract Details (All plans are Non-Participating)
Single Premium of $ paid on D D M M M Y Y Y Y Use Additional Information or instructions if additional space is required.
Annuity Measuring Annuity Annuity Commencement
No. Life Type Guaranteed Option Payment Frequency Date Term
(1-4) (TC, SL, JL, Guaranteed LCR IR M/Q/S/A (Between 1st and 28th) (TSL and TJL only)
TSL,TJL) Period (all types)(SL only) (SL and JL only)
1 Y Y M M
$ D D M M M Y Y Y YY Y M M 2 Y Y M M
$ D D M M M Y Y Y YY Y M M 3 Y Y M M
$ D D M M M Y Y Y YY Y M M 4 Y Y M M
$ D D M M M Y Y Y YY Y M M 5 Y Y M M
$ D D M M M Y Y Y YY Y M M D D M M M Y Y Y Y D D M M M Y Y Y Y D D M M M Y Y Y Y D D M M M Y Y Y Y
4 Contract Details (All plans are Non-Participating)
Annuity Indexation of Annuity Payments Joint Life Reduction
No. Commencement Date CPI Time
No Percentage or Dollar No Percentage or Dollar On Death of
Indexation Amount Reduction Amount Prime or First
1
% or $
D D M M M Y Y Y Y
% or $ 2
% or $
D D M M M Y Y Y Y
% or $ 3
% or $
D D M M M Y Y Y Y
% or $ 4
% or $
D D M M M Y Y Y Y
% or $ 5
% or $
D D M M M Y Y Y Y
% or $ Lump SumsMeasuring Life Lump Sum Payment Life Payment Date Measuring Life Lump Sum Payment Life Payment Date
(1-4) Contingent (1-4) Contingent $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y Y $
D D M M M Y Y Y YAdditional information or instructions:
Additions and Amendments (for Standard Life use only):
5 Contract Provisions and Schedule
This application, along with the Structured Settlement Annuity Provisions and the Schedule constitute the entire Contract between the Owner and Standard Life. It is understood that the contract will not be assigned, and that the Annuity Payments will not be commuted, assigned or encumbered and the Annuity Payments are irrevocably directed to the Measuring Life(ves).
6 Declaration and Signatures
The person signing as Owner declares that the answers and statements in this application are complete and true to the best of his or her knowledge and belief. It is agreed that: 1. The Contract will take effect on the date when the Single
Premium is paid, even if the Measuring Life dies after that date but before the Contract is issued.
2. Acceptance of the Contract will constitute agreement to its terms and to any changes specified by the Company in the Contract. Unless otherwise directed, any payment falling due on or after the death of the Measuring Life(ves) will be payable to the Estate of the said Measuring Life(ves).
Signed at this day of ,
month year
X X
Owner, Annuitant, (Beneficiary) Joint Owner (if any)
X
Witness (Insurance Representative) Insurance Representative Name (In block letters)
7 Notice to Owner(s), Annuitant(s), Beneficiary(ies)
Standard Life Assurance Limited is a UK insurer which is authorized to carry on insurance business in Canada. The Contract being applied for, if accepted, will be issued or made in the course of its insurance business in Canada.
The transaction represented by this application is between the Owner and Standard Life. The person soliciting this application is an independent contractor and will receive compensation from Standard Life upon the completion of this transaction. The applicant is not obligated to transact any other business with Standard Life as a condition of this transaction.
8 Insurance Representative Certification
I have completed this application form with the owner/annuitant(s) and hold a valid insurance license in the jurisdiction where the application was signed. I have disclosed the following information to the client(s):
• the life insurance company or companies I represent;
• that I will receive compensation by way of commission income for the sale of life insurance company products; • that I may qualify for conference programs or other incentives based on annual sales volume; and
• any conflict of interest I may have with respect to this transaction.
Insurance Representative (In block letters) Insurance Representative Code
Signature of Insurance Representative Date
Other
(Between 1st and 28th) Partial/ Immediate/Full Deferred
(Before/ After gtd. period)
Ann. Jan 1st
St ru ctur ed Se tt le m en t Ann ui ty dir ect d eposi t se rvi ce Own er Measur ing Lif e I request that STANDARD LIFE
deposit the Annuity Payments directly into the following bank
account; (a personalized voided specimen cheque should be attached, if available) N ame of P ay ee N
ame of financial ins
titution Addr ess of financial ins titution City Pr ovince P os tal Code T
elephone no. of financial ins
titution Account T ransit N umber Ins titution N umber A ccount N umber Signatur e of P ay ee Dat e Use Additional inf or mation or ins tr uctions if additional space is r equir ed.
The Standard Life Assurance Company of Canada 1022J 10-2011 ©2011 Standard Life
