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NOTICE AND SIGNATURE AUTHORIZATION
NUMBER 
TITLE
DATE
4397-00A Notice and Signature Authorization                                                          JUN2017

 

 

TEMPORARY INSURANCE CERTIFICATE (TIA)
NUMBER 
TITLE
DATE
5801-00A Golden Protection & No Medical Certificate (TIA) OCT2016
5755-00A
Term & Permanent Certificate (TIA)
   MAR2016

 

 

DATA COLLECTION FORM
NUMBER
TITLE   
DATE
Data Collection Form - Golden Protection & Golden Protection Deferred
Also print the Notice and Sign. form
JAN2017
4667-00A
Data Collection Form - FlexOptions
Also print the Notice and Sign. form
MAY2017
4669-00A
Data Collection Form - FlexTerm 
Also print the Notice and Sign. form
MAY2017
4796-00A
Data Collection Form - ParPlus
Also print the Notice and Sign. form

MAY2017
4798-00A
Data Collection Form - ParPlus Jr.
Also print the Notice and Sign. form
MAY2017
4935-00A
Data Collection Form - Youth Plus
Also print the Notice and Sign. form
MAY2017
5085-00A
Data Collection Form - Total Protection  
Also print the Notice and Sign. form
MAY2017
5397-00A Data Collection Form - Critical Protection
Also print the Notice and Sign. form
MAY2017
5885-00A
Data Collection Form - No Medical Exam 
Also print the Notice and Sign. form
JAN 2017
 

 

 
APPLICATIONS
NUMBER  
TITLE
DATE
5208-01A Application for Accidental Fracture Plus Rider                                                    OCT2013
4815-00A Application for Conversion MAR2015
4615-00A Application for Golden Protection JAN2017
5041-00A
Order form - Golden Protection paper application
JAN2016
Child Insurance Benefit Form
APR2013
Application for conversion of simplified life insurance
NOV2016
5739-00A
Application for modification of the term of a FlexTerm policy
MAR2017
 

 

DECLARATION OF INSURABILITY
NUMBER
TITLE
DATE
5267-00A Declaration of Insurability - InstaTerm  JUL2016
5269-00A Declaration of Insurability - InstaTerm Deferred JUL2016
5877-00A Declaration of Insurability - No Medical Whole Life - Immediate & No Medical Term - Immediate JAN2017
5879-00A Declaration of Insurability - No Medical Whole Life - Deferred & No Medical Term - Deferred OCT2016
3952-00A Declaration of Insurability - Traditional Products (including Critical Protection issued since July 2014) DEC2016
4548-00A Declaration of Insurability - Total Protection only issued Dec.01,2004    JAN2017
Declaration of Insurability - Golden Protection & Golden Protection Plus
DEC2016
Declaration of Insurability - Golden Protection Deferred JUL2016
Declaration of Insurability - Critical Protection issued before June 2012
JAN2017
 

 

CLAIMS
NUMBER
TITLE
DATE
4756-00A Accidental Fracture Plus - Claims Questionnaire NOV2014
4226-00A Attending Physician's Statement - Long-term Disability Benefit         JUL2014
4802-00A Claimant's Statement - Death Claim NOV2014
3998-00A  Claimant's Statement - Extension of Disability        AUG2012
3817-00A Claimant's Statement - Total Disability Claim        NOV2014
4765-00A Foreign Death Questionnaire MAY2014
3073-00A    Physician's Statement - Proof of Death        FEB2012
5411-00A Physician’s Statement – Critical Illness Insurance - Blindness MAR2015
5405-00A Physician’s Statement – Critical Illness Insurance - Cancer - Life-Threatening MAR2015
5403-00A Physician’s Statement – Critical Illness - Neurological Disorders MAR2015
5401-00A Physician’s Statement – Critical Illness Insurance - Cardiovascular Disorders MAR2015
5407-00A Physician’s Statement – Critical Illness Insurance - Organ Failure MAR2015
5409-00A Physician’s Statement – Critical Illness Insurance - Severe Burns MAR2015
Financial Institution Form - Disability insurance based on a loan
SEP2014
Employer's Statement - Disability insurance based on employment income
MAY2014
Critical Illness Claimant Statement
JAN2015
 




CLIENT SERVICE 
NUMBER
TITLE
DATE
4819-00A Life Insurance Policy Replacement Declaration       2010
0000-04A Your Obligations - Life Insurance Policy Replacement        APR2016
3151-00A Policy Loan Repayment MAR2016
3001-00A Policy Service Request JAN2017
4791-00A Request for Preauthorized Debit Plan (PAD) APR2016
Policy Loan
FEB2014
5251-00A Change of Beneficiary  JUL2015
5623-00A Change of Beneficiary - Substitute Beneficiary Option JUL2015
5737-00A Transfers Between Investment Accounts  NOV2015
 

 

UNDERWRITING MEDICAL QUESTIONNAIRES
NUMBER 
TITLE
DATE          
4413-00A Arthritis, Rheumatism or Gout Questionnaire                                        AUG2013
4473-00A Authorization of Proposed Insured (1) and (2)                                                    AUG2013
3881-00A Back Pain Questionnaire AUG2013
3884-00A Chest Pain Questionnaire AUG2013
3888-00A Convulsion Questionnaire AUG2013
3886-00A Diabetes Questionnaire AUG2013
3894-00A Gastro-Intestinal Questionnaire AUG2013
3896-00A Heart Examination Questionnaire (Attending Physician) AUG2013
3900-00A Psychological or Nervous Disorder Questionnaire NOV2015
3907-00A Respiratory Disorder Questionnaire AUG2013
Diabetes Questionnaire (to be completed by attending physician)
SEP2013
Musculoskeletal Disorder Questionnaire
NOV2014
Authorization to Disclose Personal Information SEPT2015
 
UNDERWRITING SPORTS & LIFESTYLE QUESTIONNAIRES
NUMBER
TITLE
DATE
3876-01A Alcohol Use Questionnaire                                                                                  FEB2013
3877-01A Automobile Racing Questionnaire                                                       FEB2013
3880-01A Aviation Questionnaire FEB2013
3882-00A Ballooning/Hang Gliding/Ultralight Questionnaire FEB2013
4018-00A Driving Record Questionnaire JUL2013
3887-01A Drug Usage Questionnaire JAN2017
3890-00A Financial Questionnaire OCT2012
3893-00A Foreign Travel & Residence Questionnaire      FEB2013
4885-00A Hazardous Sports and Activities Questionnaire JUNE2016
3902-00A Motorcycle Questionnaire FEB2013
3903-00A Mountaineering Questionnaire  FEB2013
3905-00A Parachuting/Sky Diving Questionnaire  FEB2013
3906-00A Power Boat Racing Questionnaire FEB2013
3908-01A Scuba Diving Questionnaire FEB2013
3909-00A Snowmobiling Questionnaire NOV2005
3910-00A Tobacco Usage Questionnaire JUNE2016
3970-00A Disability Insurance Questionnaire FEB2013
Military Questionnaire
SEP2013
Work and Study Permit Questionnaire
MAR2015
Criminal Activity Questionnaire
MAR2014
 
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