• No results found

Application for Annuity Annuity Plus Foresters Retirement Income Funds Plus

N/A
N/A
Protected

Academic year: 2021

Share "Application for Annuity Annuity Plus Foresters Retirement Income Funds Plus"

Copied!
7
0
0

Loading.... (view fulltext now)

Full text

(1)

foresters.com

Application for Annuity

• Annuity Plus

• Foresters Retirement Income Funds Plus

(2)

Application for Annuity

For purposes of all pages of this document the following words and phrases are defined. The word “application” means this application for Annuity. The acronym “FR” means the Foresters Financial Representative who signed this application. The words “we”, “our” and “us” mean The Independent Order of Foresters ("Foresters"). The words “you”, “your” and “Proposed Annuitant(s)” mean the person(s) proposed as an annuitant in this application. The acronym “FRIF Plus” stands for Foresters Retirement Income Funds Plus. The term “GIA” refers to Guaranteed Interest Account, with the number following the term “GIA” representing the length (in years) of the account.

General Information

foresters.com

/12)

Please note order of birth date is (mmm/dd/yyyy).

All phone numbers must include area code.

Information about the Proposed Annuitant

Name (first, middle, last)

Social insurance number Birth date (mmm/dd/yyyy)

Marital status

Home address (use mailing address) Home phone number City, province Postal code

Are you a member of Foresters? Yes. Indicate certificate number(s). No. Applying for membership.

Original document shown to verify identity. Driver’s license number and province Passeport Other government I.D.

Document number Male Female Beneficiary Information Rights of a contingent beneficiary only arise if no primary beneficiary is living when the annuitant dies.

Name and address of each primary beneficiary

of the Proposed Annuitant Relationship

% Share

Total must equal 100%. Name and address of each contingent beneficiary

of the Proposed Annuitant Relationship

% Share

Total must equal 100%.

(3)

/12)

Page 3 of 7 This annuity is being applied for as:

Registered Annuity Plus Locked-in

Not locked-in

You have requested Foresters apply to register the certificate as a Retirement Savings Plan under the Income Tax Act (Canada) and any applicable provincial Income Tax Act.

Non-registered Annuity Plus

Amount being paid to Foresters by cheque along with this application $ Amount being transferred under the Income Tax Act (Canada)

by the Company(ies) indicated on the transfer form(s) $

(estimated amount)

Establish Pre-Authorized Chequing (PAC) amount $

Establish Billings amount $

Billing or Pre-Authorized Chequing frequency

Monthly (PAC only) Quarterly Semi Annual Annual No Billing/PAC

Contributor (if other than Proposed Annuitant)

Name (first, middle, last)

Social insurance number

Contributor is

Spouse or common-law partner or Other (non-Registered only)

Relationship to Proposed Annuitant (if Other)

Original document shown to verify identity. Driver’s license number and province Passeport Other government I.D.

Document number

Allocation of Premium

Accounts Sum PercentageInitial Lump

Daily Interest Account %

GIA-1 Year % GIA-2 Years % GIA-3 Years % GIA-4 Years % GIA-5 Years % GIA-10 Years %

(Total must equal 100%) (Whole numbers only) Annuity Plus • Complete this page only if applying for an Annuity Plus certificate • Completed PAC Card and void cheque required if PAC selected

• Completed only if contributor is not the Proposed Annuitant

(4)

/12) I request Foresters apply to register the certificate as a Retirement Income Fund under

the Income Tax Act (Canada) and any applicable provincial Income Tax Act. Amount being transferred under the Income Tax Act (Canada)

by the Company(ies) indicated on the transfer form(s) $

(estimated amount)

Mode of Income Payments

Monthly (Direct Deposit only) Semi-Annual (Direct Deposit or cheque) Quarterly (Direct Deposit or cheque) Annual (Direct Deposit or cheque) Method of Income Payments

Direct Deposit (void cheque required, all modes) Cheque (Quarterly, Semi-Annual, Annual)

Schedule of Income Payments (Amount requested must meet current administrative rules) Minimum

Level Payment of $ prior to tax withholding

Level Payment of $ after tax withholding

Minimum Income Payments

Is the Minimum Income Payment based on your spouse or common-law partner’s age?

No Yes (if “Yes”, please provide the following spouse or common-law partner information) Spouse or Common-Law Partner Information

Name (first, middle, last)

Birth date (mmm/dd/yyyy)

Original document shown to verify identity and date of birth. Driver’s license number and province

Passeport Other government I.D.

Document number

Income Payment Start Date

I wish for my income payments to start in /

(mmm/aaaa)

Foresters Retirement Income Funds Plus Complete this page

only if applying for a Foresters Retirement

Income Funds Plus certificate.

• Select only one mode

• Select only one method

• Attach void cheque if Direct Deposit selected • Select only one

schedule • Minimum Income Payments may be in excess of requested level payment

• Select either Yes or No

• No later than December of the year after issue • Premium Allocation is for payments made to Foresters • Income Payment Allocation is for payments made by Foresters to you Premium Allocation (premiums paid to Foresters)

Investment Accounts Percentage

Daily Interest Account 129 %

GIA-1 Year 131 % GIA-2 Years 132 % GIA-3 Years 133 % GIA-4 Years 134 % GIA-5 Years 135 % GIA-10 Years 130 %

Canadian Money Market Fund 054 %

Canadian Balanced Fund 053 %

Canadian Bond Fund 051 %

Canadian Equity Fund 052 %

Canadian Index Fund 062 %

American Index Fund 061 %

Eurasia Index Fund 063 %

Global Index Fund 064 %

(Total must equal 100%) (Whole numbers only)

Income Payment Allocation (payment made by Foresters to you)

Investment Accounts Percentage

Daily Interest Account 129 %

GIA-1 Year 131 % GIA-2 Years 132 % GIA-3 Years 133 % GIA-4 Years 134 % GIA-5 Years 135 % GIA-10 Years 130 %

Canadian Money Market Fund 054 %

Canadian Balanced Fund 053 %

Canadian Bond Fund 051 %

Canadian Equity Fund 052 %

Canadian Index Fund 062 %

American Index Fund 061 %

Eurasia Index Fund 063 %

Global Index Fund 064 %

(5)

Other Annuity or Insurance Contracts

Do you have another annuity application pending with Foresters or any other insurer?. . . Yes No Will a Proposed Annuitant stop paying premiums, reduce the face amount of coverage or otherwise discontinue

existing life insurance coverage or an annuity if the annuity applied for in the application is issued? . . . . Yesi No (If ‘Yes’, complete Foresters replacement / rollover / disclosure & comparison statements. Include existing life

insurance or annuities in the process of being lapsed or surrendered, and those completed within the past 13 months.) Agreements applicable to Proposed Annuitant(s)

“I/we” means the Proposed Annuitant, owner (if applicable), Proposed Annuitant’s spouse or common-law partner (if applying for an Annuity Plus and the Annuity Plus is to be a “spousal or common-law partner contributor” plan, or if applying for a FRIF Plus and the Minimum Income Payment is to be based on the age of the spouse or common-law partner of the Proposed Annuitant), and parent (if juvenile coverage is applied for), signing below. I, as evidenced by my signature below, have read, understood, agree, and declare:

1. I have read this application and confirm that every question was asked and the answers contained herein are complete and true to the best of my knowledge and belief. All statements made in this application shall be representations and not warranties.

2. No person, including a FR, has the authority to waive the disclosure of full, complete and truthful information in response to each question in this application. Such person also has no authority to write down an answer given to a question in the application other than the answer that was provided to the FR.

3. The certificate will not take effect until both (a) and (b) immediately below are met. (a) The certificate has been delivered to the Proposed Annuitant, or owner.

(b) Initial premium(s) is/are paid during the lifetime of the Proposed Annuitant(s).

A cheque provided to Foresters is not paid to Foresters unless and until the cheque is honored for payment by the banking institution of the account from which the payment is to be drawn.

4. I understand the potential consequences of deliberately providing false information in this application. 5. Any cheques must be payable to Foresters.

6. Products offered under the “Annuity Plus” section of this application are comprised of Daily Interest Account, and Guaranteed Interest Accounts. The surrender of the certificate and each withdrawal, or transfer of money, is subject to market value adjustments.

7. Investment Options offered under the “FRIF Plus” section of this application are comprised of a Daily Interest Account, Guaranteed Interest Accounts of various terms, and Segregated Funds. The surrender of a FRIF Plus certificate will be subject to surrender charges, and market value adjustment. Each withdrawal from a FRIF Plus certificate is subject to surrender charges, market value adjustments and an administration fee. The transfer of money between investment options is subject to market value adjustment and an administration fee.

8. I have received and read the document entitled “Privacy Notice” which describes the policy and practices of The Independent Order of Foresters and its wholly owned subsidiaries with respect to their collection, use, disclosure and retention of personal information.

The parties hereto state their express wish that this Agreement as well as all documentation contemplated hereby or pertaining hereto or to be executed in connection herewith be drawn up in English French

Special Instructions.

Signed at:

City, province Date (mmm/dd/yyyy)

Signature of Proposed Annuitant

Signature of owner (if not Proposed Annuitant) Signature of parent (if Proposed Annuitant is juvenile)

Signature of Proposed Annuitant’s spouse or common-law partner (if applicable) Date (mmm/dd/yyyy)

Signature of the Proposed Annuitant’s spouse or common-law partner only needed if applying for an Annuity Plus and the Annuity Plus is to be a “spousal or common-law partner contributor” plan, or if applying for a FRIF Plus and the Minimum Income Payment is to be based on the age of the spouse or common-law partner of the Proposed Annuitant.

/12)

Page 5 of 7 Owner and parent

(6)

FR Certification I certify that:

• I asked all questions as written in the application. I have recorded all answers as given to me by the Proposed Annuitant(s).

• I have not made or agreed to make a rebate of the premium for this annuity.

• I recommend acceptance of this application except as qualified in Special Instructions.

• I have made no misrepresentation(s) about the Foresters product(s) applied for in this application. I have made no promise(s) regarding the benefit(s) or future performance of the product applied for, other than as specifically written in the specific product applied for in this application.

• I have complied with all regulatory requirements applicable to this application.

• I personally witnessed the signature(s) of the person(s) whose signature(s) appear in this application. • I personally reviewed the original photo identification of the person(s) who signed this application. Will the Annuity Plus or FRIF Plus certificate applied for in this application, to the best

of your knowledge, replace any existing life insurance contract or annuity contract held

by the Proposed Annuitant/Owner? . . . Yes No (if “Yes”, please ensure details are noted in Special Instructions or below, in the Details/Notes section)

Full printed name of FR FR Signature Date (mmm/dd/yyyy)

Details/Notes

FR # Branch # Office #

For Internal Use Only Certificate #

(7)

Page 7 of 7

The Independent Order of Foresters, 789 Don Mills Road, Toronto, ON M3C 1T9, Canada T 800 828 1540 T 416 429 3000 F 416 429 3896

Foresters™ is the trade name and a trademark of The Independent Order of Foresters and its subsidiaries are licensed to use this mark.

Attach Void Cheque

/12)

Payment Information and

Pre-Authorized Chequing (PAC) Authorization

First premium payment to be made by cheque (payable to Foresters)

PAC Authorization

The payor signing below verifies that the payor is an account holder of the account identified on the attached VOID cheque or in the banking information section above and agrees that:

1. Foresters is authorized to draft deductions under the PAC plan from that account or another account later

identified or substituted by the payor, for premium and charges for the insurance contract(s) issued in response to the application for the insurance contract(s) to which this PAC Authorization relates;

2. The financial institution from which payments are to be drafted is authorized to treat each draft by Foresters as though the payor made it personally;

3. Foresters reserves the right to determine when the first deduction, if any, will be made and the amount of that deduction for the product issued, however, it will be after the issue date(s) of the applicable insurance contract(s) issued, if any;

4. The PAC plan is effective immediately and will continue until terminated, which either the payor or Foresters may do by providing written notice of 30 days to the other. Payor may obtain a sample cancellation form or further information on the right to cancel a PAC Agreement at his/her financial institution or by visiting www.cdnpay.ca; 5. Should funds not be available due to insufficient funds, the payor authorizes Foresters to draft my account on the next available withdrawal date for those insufficient funds while the applicable insurance contract is in effect; and 6. I understand 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 the PAC Agreement. To obtain more information on your recourse rights, contact your financial institution or by visiting www.cdnpay.ca. The Payor waives the right to receive pre-notification of the amount and date of the first debit and of a change in a debit amount required as premium for the insurance contract(s) in effect or a change requested by the Payor by any means.

The payor account holder must sign this agreement as his/her name appears on bank records for the account provided.

X

Name of Account Holder Signature of Account Holder Date (mmm/dd/yyyy)

The payor may contact Foresters at the address and phone numbers shown below:

Monthly PAC Withdrawals are: Personal related Business related

Withdrawal date requested (Check one): 1st 8th 15th 22nd

PAC banking information to be taken from: VOID cheque - must be attached

Banking Information completed below (Use only if no cheque available)

Type of account: Chequing Savings

References

Related documents

If poor market performance, declining interest rates, or Automatic Income Benefit Purchases cause your policy to dip in value below what is needed to fund your Guaranteed

If you keep your contract for at least five years, you can choose to receive annuity payments, which are the payments we make back to you over a period of time, based on

Allianz Endurance Plus combines the benefit of enhanced retirement income withdrawal options with the reassurance of a fixed index annuity to create a versatile and flexible

With John Hancock’s Guaranteed Principal Annuity (GPA) Plus, you’ll get the security of a guaranteed interest rate, plus the exceptional strength and stability that John Hancock

{¶49} Under the plain language of annuity documents, Symetra was the owner of the annuity and the decedent was merely the annuitant with no right, no legal or equitable interest

☐ Joint and last survivor life annuity (successor annuitant) at _____% (You accept that upon the death of the annuitant and his/her spouse, annuity payments will terminate; no

I understand that if I have selected an annuity that does not include a guarantee period, the annuity income payments will cease when the annuitant dies or if this is an annuity

At the death of the Annuitant before the Annuity Date, the beneficiary will receive an income settlement option based on the full Accumulation Account. This allows the annuity owner