nn0943e - request to split an individual insurance policy · ♦ use this form to request a policy...

Approval of a request to split or change a coverage type on an individual insurance policy is subject to our current administrative rules.

How and when to use this form:

♦ Use this form to request a policy split for an individual life insurance, critical illness, or long-term care policy.

♦ See product specific instructions below.

♦ If you need additional space on this form, use section 9, Additional instructions, or attach a separate sheet of paper that has been signed, dated, and witnessed.

♦ All information on this form will be shared with all policy owners, original and new. You may choose to submit personal information on separate forms by using:♦ Request to change address information, NN1572E,♦ Beneficiary designation, NN0283E (applies to life and combination insurance policies),♦ Set up or change a pre-authorized debit plan, NN0312E.

For any individual insurance policy, excluding Performax Gold policies issued on or after November 21, 2015, start at section 2 and:

♦ describe the changes to be made to the existing policy as a result of the policy split under the Existing policy columns, starting at section 2,

♦ describe any changes to be made to the new policy as a result of the policy split under the New policy columns, starting at section 2.

For a coverage type change on a Performax Gold joint first-to-die coverages on policies issued on or before November 21, 2015:

To apply for a:

♦ coverage type change from a joint-first-to-die coverage to two single-life coverages, complete section 1, then continue with sections 12, 13 and 14,

♦ coverage type change and a policy split, complete the entire form starting at section 1.

For Performax Gold policies issued on or after November 21, 2015:You can’t use this form to make changes to Performax Gold policies issued after this date. Contact our Customer Service Centre or Advisor Support Centre for information on your options and the forms you will need to complete.

To split a multi-plan policy:♦ complete Request to split a multi-plan insurance policy, NN0997E.

(additional information is on the next page)

The Manufacturers Life Insurance Company NN0943E (01/2020) of 19

Request to split an individual insurance policy

Additional information for all policies

♦ Submit a void cheque showing new banking details, if applicable.

♦ Submit a premium payment or deposit for the new policy, if applicable.

Additional information for life insurance policies:

♦ If you want to change a coverage type without changing the ownership:

♦ For Performax or Performax Gold policies use Request for change for Performax Gold and Performax policies Evidence of insurability NOT required, NN0739E(PMAX),

♦ For other life insurance policies, use Request for change Evidence of insurability NOT required, NN0739E.

♦ If you want to change the ownership only use, Transfer of ownership, NN0687E.

♦ If you want to change a coverage type only and want to change the beneficiaries of the existing coverage, use Beneficiary designation at a coverage level, NN0772E.

♦ If you are requesting a policy split for Performax Gold or universal life policy, or permanent life policy with a side account and want to change the ownership of either policy, submit a completed Identifying owners of Individual Insurance policies, NN1558E for each change in ownership requested.

You must also submit a product page and signed illustration for all universal life, permanent life insurance with side accounts, and Performax Gold, policy split requests.

Mail this form to Manulife at:

All provinces except QuebecIndividual Insurance500 King Street NorthPO BOX 1669WATERLOO ON N2J 4Z6

Fax: 1-877-763-8834

manulife.ca

Customer service centre:All provinces except Quebec 1-888-626-8543Quebec 1-888-626-8843,Outside of North America 519-747-6600 (call collect)

In QuebecAssurance individuelle2000 rue Mansfield, bureau 1310MONTREAL QC H3A 3A1

Fax: 1-877-271-5494


Note: The Joint-first-to-die coverage identified in this section will be cancelled when we approve the change. We will issue two new current-dated single-life coverages on the policy identified in section 1.0.

Note: Coverage type changes are not available on:• Policies with more than two

insureds, or• Joint last-to-die coverages.

* Contact head office for thecurrent cash values required tocomplete this form.

Maximum amount of insurance for each new current-dated single-life coverage

$

Base insurance coverage amount

$

Base insurance coverage amount

$

Term option amount*

$

Term option amount*

$


1.0 Performax Gold coverage type change for Joint-first-to-die coverages

1.1 Performax Gold - Calculating the maximum amount of insurance for each new current-dated single-life coverage

Policy number

Name of insured person A (first, middle initial, last)

Name of insured person B (first, middle initial, last)

Joint first-to-die coverage number

To calculate the total amount of insurance on your existing Joint-first-to-die coverage, complete the chart below.

To calculate the maximum amount of insurance for each new current-dated single-life coverage, use the amounts you calculated in the chart above to complete this equation:

If the Joint-first-to-die coverage has a performance credit option of Term option, tell us how much of the maximum amount of insurance you want as base insurance coverage and how much you want as Term option.

Name of coverage or rider

Base coverage

Yearly term insurance (if applicable)

Paid-up insurance (if applicable)

Deposit option insurance (if applicable)

Total

Sum Assured/Death Benefit Amount

$

$

$

$

A=

Cash value *

$

***N/A***

$

$

B=

[A + (A-B)] / 2 =

Insured person A

Insured person B

Performax Gold coverage type change for Joint-first-to-die coverages• Complete part 1 to request to change a Performax Gold Joint-first-to-die coverage to two

new current-dated single-life coverages.• We, us and our refer to The Manufacturers Life Insurance Company.• You and your refer to the owner(s) of the policy identified in section 1.0 unless

otherwise specified.To request a policy split, go to section 2.0.

* You must enter at least $1000.


1.2 Performax Gold – Special purchase of deposit option insurance

1.3 Performax Gold – Unused accumulation account amounts

1.4 Performax Gold – Allocating your additional payments

Note: If the performance credit option is Term option, the application of a special deposit option payment will result in a recalculation of the term option components yearly term insurance and deposit option insurance.

The effective date for additional payments is the business day we receive the funds at our head office.

If the Joint-first-to-die coverage had deposit option insurance with a remaining lifetime deposit option limit greater than $0, the new single-life coverage will include a deposit option insurance coverage with the option to make a one-time deposit option purchase. You must request the one-time deposit option purchase on this form. You cannot request a one-time deposit option purchase after this coverage type change has been processed.The maximum amount available for each deposit option insurance coverage is limited to 50% of the amount released into the accumulation account as a result of the Joint-first-to-die coverage type change.To calculate the maximum amount available for each deposit option insurance coverage, use the amounts you calculated in the chart in section 1.0 to complete this equation:

Any cash value and/or unused costs released because of this coverage type change will be placed in your accumulation account and can be withdrawn by you, subject to taxation and administrative rules.Do you want to withdraw any cash value and/or unused costs released?

Complete this section if you have deposit option insurance and want to allocate new additional payments or future additional payments. The instructions identified below apply to (check one or both):

Maximum amount available to purchase deposit option insurance for each coverage

$B / 2 =

Insured person ADo you want to make a special purchase of deposit option insurance for Insured person A?

Accumulation account amount applied to buy deposit option insurance

$

Percentage of accumulation account applied to buy deposit option insurance

%OR

No

This additional payment of:

All future additional payments

Yes

No Yes

If yes, tell us:

If yes, tell us: the amount you want to withdraw: $

$

Tell us how you want to allocate your additional payment % of additional payment allocated

To deposit option insurance coverage number



To accumulation account

%

%

%

%

Total

Insured person BDo you want to make a special purchase of deposit option insurance for Insured person B?

Accumulation account amount applied to buy deposit option insurance

$

Percentage of accumulation account applied to buy deposit option insurance

%OR

No Yes If yes, tell us:

100%


life insurance policy: If the existing owner on a life insurance policy changes there may be tax consequences, such as a taxable gain and/or the loss of preferential tax treatment. It is important that you discuss the tax implications of this change with your tax and legal advisors. Initial to confirm you understand that all information will be shared with all owners and that you understand the tax implications.

critical illness policy: initial to confirm you understand all information will be shared with all owners.long term care policy: initial to confirm you understand all information will be shared with all owners.

This request is to split a:

Move

Divide and move

OR

When you split a coverage to a new policy, you can:• move an entire coverage to a new policy.• divide and move a portion of a coverage to a new policy. The other portion of that coverage will remain

on the existing policy.

Tell us what you want to do (select one):Unused modal costs, yearly term insurance costs and the accumulation account values are allocated according to our administrative rules.

Complete this section if you are dividing and moving a portion of a coverage to the new policy.Base insurance coverage amount to move to the new policy

Request to split an individual insurance policy

2.0 Existing policy

3.0 General information

4.0 Performax Gold information about the coverage you want to split to a new policy

Policy number

Your initials

Coverage number

Coverage number

Name of Insured person

Name of Insured person

All information on this form will be shared with all policy owners, original and new. You may choose to maintain privacy by giving us your beneficiary and banking information on separate forms that we list in those sections.Once you have properly completed and signed this request to split a policy, it’s a legal document that is evidence of a policy change, and if applicable, an ownership change. Manulife cannot reverse these changes. The change is effective on the day this form is received at Manulife’s head office, complete and in good order.

For Performax Gold coverages only; all other policies go to section 5.0

When we approve this request, existing beneficiary designations are revoked and benefits are paid to the new owners or to their estate. Complete section 10.2 Beneficiary information for life insurance, or submit a Beneficiary designation, NN0283E separately, to confirm the beneficiaries, if you are requesting an ownership change.

• you understand that all information on this form will be shared with allpolicy owners, existing and new, and

• for life insurance policies, you fully understand the tax implicationsof this change and that, if appropriate, you have discussed theseimplications with your tax and/or legal advisor.

Note: A portion of any outstanding loan amount on the policy identified in section 2.0 on the date the policy change is processed will be transferred to the new policy. A new interest rate for the loan may apply.

for

for

to a new policy

to a new policy

Amount of base insurance coverage to move to the new policy

$

All owners initial here to confirm that:

• Complete the remainder of this form beginning at section 2.0 to request that anindividual insurance policy be split to a new policy.

• Complete one form per policy; for another policy submit a second form.• We, us and our refer to The Manufacturers Life Insurance Company. You and your refer

to the policy owners, unless otherwise specified.


5.0 Ownership information

5.1 Mailing address

5.2 Other policy information

*Social insurance number is not required for Long term care policies.

A Business number is a number assigned to a business for tax purposes, such as filing an income tax return. The Income Tax Act (Canada) requires us to collect and record this number if a policy is owned by corporation.

Owner’s mailing address: select one owner for each policy to receive all correspondence relating to these policies and provide the mailing information.You may choose to provide this information instead by submitting a separate Request to change address information, NN1572E.

Existing policy

Existing policy New policy


New policy

Is the owner of the existing policy changing?Who will own the new policy?

Will the money to pay the premiums for this policy be borrowed from an unrelated individual, a bank, or other institution?

Is there an existing agreement, or do you plan to sign an agreement within the next two years, that will result in someone other than you having any rights or legal interest in this policy?

Name of new owner #1 (first, middle initial, last) Name of new policy owner #1 (first, middle initial, last)

Name (first, middle initial, last) or company name Name (first, middle initial, last) or company name

Address (street and number) Address (street and number)

City or town City or town

Province ProvincePostal code Postal code

Name of new owner #2 (first, middle initial, last) Name of new policy owner #2 (first, middle initial, last)

Male Male

Male Male

Female Female

Female Female

Sex Sex

Sex Sex

Social insurance number* Social insurance number*

Social insurance number* Social insurance number*

Full legal name of entity #1 Full legal name of new policy’s entity #1

Full legal name of entity #2 Full legal name of new policy’s entity #2

Business number or Trust account number




Relationship to Insured person Relationship to Insured person

Relationship to Insured person Relationship to Insured person

Date of birth (dd/mmm/yyyy) Date of birth (dd/mmm/yyyy)

Date of birth (dd/mmm/yyyy) Date of birth (dd/mmm/yyyy)

No

No

Yes

Yes

If yes, provide details:


OR (use, if applicable, for corporate owner, trust, etc.) OR (use, if applicable, for corporate owner, trust, etc.)

If no, go to section 6If yes, tell us the information below

NoYes

No

No

Yes

Yes



No Yes


Existing policy

Existing policy

Existing policy

New policy

New policy

New policy

5.3 Relationship information

5.4 Multiple owners

5.5 Naming a subrogated owner for any Quebec policy

This section applies to all Quebec policies.

For life insurance only; for long term care or critical illness policies, go to section 5.4.Relationship is required to help us determine the tax consequences of the transfer.

Complete this section for a policy governed by Quebec legislation if you want to name another person to receive an owner’s interest in this policy after his or her death. We recommend that you do this if the policy may continue after a policy owner’s death.

Current owner’s relationship for tax purposes to the new owner

If a current owner and new owner are both individuals:

If either a current owner or a new owner is an entity are the current owner and the new owner related for tax purposes?

Multiple owners in all provinces except Quebec: If more than one owner is being named, we will set up the ownership as joint ownership with right of survivorship. This means policy ownership is shared between the joint policy owners and, if the policy is still in effect after the death of one of the joint owners, the deceased owner’s share automatically passes to the surviving joint owner or owners. If you want ownership of your policy to be set as a tenants in common instead of joint ownership with right of survivorship, check the box below:

Multiple owners in Quebec: If this policy is to be owned by more than one person, and if the policy is still in effect after the death of one of the owners, that owner’s interest will pass to their estate unless a subrogated policy owner has been named for that person’s interest in the policy.

Was any money or other consideration exchanged between a new owner and a current owner for the ownership change?

• Are the current owner and new owner related for tax purposes? If yes, what is the relationship of the new owner to the current owner (be specific, for example: child, step-child, grandchild, sibling, sibling-in-law, spouse, or common-law partner)?

• If a new owner is considered a former spouse or common-law partner of a current owner for tax purposes, is this transfer in settlement of rights arising out of their marriage or common-law partnership?

If yes, please indicate the value $

Tenants in common (If you select this option, complete Establishing Tenants in Common Ownership for a Policy, NN0967E.)

Tenants in common (If you select this option, complete Establishing Tenants in Common Ownership for a Policy, NN0967E.)

Name of owner #1 Name of new policy’s owner #1

Name of owner #2 Name of new policy’s owner #2

Name of subrogated owner (first, middle initial, last) Name of subrogated owner for new policy (first, middle initial, last)

Name of subrogated owner (first, middle initial, last) Name of subrogated owner for new policy (first, middle initial, last)

Relationship to owner Relationship to new policy’s owner


No

No

Yes

Yes

No Yes

No Yes

If either a current owner or a new owner is an entity are the current owner and the new owner related for tax purposes?

Was any money or other consideration exchanged between a new owner and a current owner for the ownership change?

• If a new owner is considered a former spouse or common-law partner of a current owner for tax purposes, is this transfer in settlement of rights arising out of their marriage or common-law partnership?

If yes, please indicate the value $

No Yes

No Yes

If a current owner and new owner are both individuals:

• Are the current owner and new owner related for tax purposes? If yes, what is the relationship of the new owner to the current owner (be specific, for example: child, step-child, grandchild, sibling, sibling-in-law, spouse, or common-law partner)?

No Yes


Existing policy

Existing policy

New policy

New policy

5.6 Naming a successor owner (in all provinces except Quebec)

6.0 Insured people

7.0 Riders

Relationship is required to help us determine the tax consequences of the transfer.

Note: If the addresses of any of the insured people on the existing policy has changed, provide new address information in section 9.

Name of owner

Insured person (first, middle initial, last)




Name of new policy’s owner

Name of successor owner (first, middle initial, last)

Name of rider Name(s) of people insured by this rider

$

$

$

$

$

$

$

$

If applicable, amount of coverage ($) toremain on

existing policymove to new

policy

Name of successor owner for new policy (first, middle initial, last)


If you want to name another person to receive the owner’s interest in this policy after his or her death, complete this section for• life insurance, or• long term care or critical illness insurance, if the legislation in your jurisdiction allows you to name a

successor owner.We recommend you do this if there is only one owner and the policy may continue after that owner’s death.

Insured people to remain on the existing policyFull name of insured person(s) who will remain on the policy.

Which rider coverages for this insured person or persons do you want to remove from the existing policy, and which do you want to be part of the new policy?

For life insurance or critical illness policies only; for long term care policies, go to section 9

Proposed people to be insured on new policyFull name of insured person(s) for the new policy.

or

or

or

or

Cancel rider

Cancel rider

Cancel rider

Cancel rider





A Do not transfer the existing policy’s last payment or value to the new policy or policies.

B Last paymentAs of the effective date of the policy split, divide the existing policy’s last payment as follows:

C Policy value (Policy value does not apply to long term care or Lifecheque policies)As of the effective date of the policy split, divide the value of the existing policy as follows:


Name of insured child Sex Date of birth (dd/mmm/yyyy)

Existing or new policy?

(select one only)

Male

Male

Male

Male

Female

Female

Female

Female

Leave on existing

Leave on existing

Leave on existing

Leave on existing

Move to new

Move to new

Move to new

Move to new

Cancel

Cancel

Cancel

Cancel

Child riders except LifechequeNote: The insured child must have been insured on the original policy. Which children insured under the rider do you want to remove from the existing policy, and which do you want to be part of the new policy?

For a Children’s Lifecheque Rider,attach the Children’s Lifecheque Rider to:

7.0 Riders (continued)

8.0 Splitting the existing policy’s last payment or value

9.0 Additional instructions

Child riders, except Lifecheque

You must complete this section for all life insurance policies.Note: Transferring funds from a minimum funded existing policy may cause the policy to go into arrears.

Children’s Lifecheque ridersName of insured parent

Select one of A, B, or C

Please use this section to add additional information or instructions, if required.

Put

Put

$

$

%

%

to the existing policy and, if applicable,

to the existing policy and, if applicable,

to the new policy

to the new policy


About beneficiary designations:• Minor children cannot give written consent to policy changes.• If you name an irrevocable beneficiary, you cannot make changes to the policy, assign its benefits or

cash value, withdraw funds from it or transfer its ownership without the beneficiary’s written approval.Parents or guardians of irrevocable beneficiaries who are children cannot give approval on their behalf.Approval must come directly from the beneficiary, and a minor cannot give this approval.

• Beneficiaries (other than a spouse under a Quebec policy) are revocable unless you specifically indicateotherwise by writing the word ‘irrevocable’ after that beneficiary’s name.

• If you believe your circumstances warrant designating your beneficiaries as irrevocable, we stronglyrecommend you first discuss this with your advisor.

This new beneficiary designation on the existing insurance policy replaces all existing beneficiary designations and applies to all insurance coverages remaining on the existing insurance policy. This beneficiary designation on the new insurance policy applies to all insurance coverages in the new policy.

If you name more than one beneficiary, please tell us the percentage of the benefit that each primary beneficiary is to receive. Otherwise, we will divide the benefit evenly among the surviving primary beneficiaries. If a person is disqualified, for any reason, from receiving a benefit payable, the benefit will be paid as if the disqualified person had died before it became payable.

Related forms for living benefits insurance (including critical illness and disability insurance under Synergy):

To designate beneficiaries for specific coverages, complete Beneficiary designation at a coverage level, NN0772E.

To designate beneficiaries in:

For Lifecheque, use

For LivingCare, use

For disability or critical illness (except Lifecheque and Synergy), use

Alberta, British Columbia, Manitoba, Ontario, Quebec or Saskatchewan:

Beneficiary designations for Lifecheque policies, NN1467E

Beneficiary designations for LivingCare policies, NN1561E

Beneficiary designations for disability policies or critical illness policies (except Lifecheque and Synergy), NN1584E

All other provinces or territories:

Direction to pay for Lifecheque policies, NN0999E

Direction to pay for LivingCare policies, NN1571E

Direction to pay for disability policies or critical illness policies (except Lifecheque and Synergy), NN1611E

10.0 Beneficiary designations

10.1 Beneficiary information for living benefits insurance


None of these designations apply to long term care policies, or critical illness policies including Lifecheque. A copy, fax, scan, or image of this beneficiary designation is as valid as the original.

For Quebec applicantsIf you name your married or civil union spouse as a beneficiary, this designation is irrevocable unless you select

For Quebec applicantsIf you name your married or civil union spouse as a beneficiary, this designation is irrevocable unless you select

10.2 Beneficiary information for life insurance

Do you want to change the beneficiary information for the insured remaining on the existing policy?

If no, go to section 11 If yes, tell us the information below or submit a separate Beneficiary designation, NN0283E.

Name of primary beneficiary (first, middle initial, last)

Relationship* % share

If the owner has not changed and you do not complete this section, the existing beneficiary designations for this policy will not change.

If the owner has changed, you must complete this section or the existing beneficiary information will be revoked and any benefits payable under the policy will be payable to the new policy owner or their estate.

For the new policy, if you do not complete this section, any benefits payable under the new policy will be payable to the owner of the new policy or their estate.

NoYes

Revocable.Revocable.







Do you want to change the beneficiary information for the insured remaining on the new policy?

If no, go to section 11 If yes, tell us the information below or submit a separate Beneficiary designation, NN0283E.

NoYes

* In Quebec, tell us the beneficiary’s relationship to the owner. In all provinces except Quebec, tell us thebeneficiary’s relationship to the insured person.


10.2 Beneficiary information for life insurance (continued)

Secondary beneficiary

A secondary beneficiary (also known as a contingent beneficiary or subrogated, in Quebec) receives a death benefit only if no primary beneficiaries are alive when the insured person dies or if all primary beneficiaries are disqualified.

Existing policy New policyName of secondary beneficiary (first, middle initial, last)


Name of secondary beneficiary (first, middle initial, last)






* In Quebec, tell us the beneficiary’s relationship to the owner. In all provinces except Quebec, tell us the beneficiary’s relationship to the insured person.

A secondary beneficiary (also known as a contingent beneficiary or subrogated, in Quebec) receives a death benefit onlyif no primary beneficiaries are alive when the insured person dies or if all primary beneficiaries are disqualified.

Trustee for minor beneficiaries (not applicable in Quebec)

Existing policy New policyName of beneficiary #1 (first, middle initial, last)

Trustee name(s) (first, middle initial, last)

Relationship of trustee to beneficiary

Name of beneficiary #1 (first, middle initial, last)









Complete this section if a beneficiary named above is a minor. Your signature in section 14.0 confirms that you agree that any benefit that becomes payable to a minor child will be paid to the trustee to hold in trust for the child until the child reaches legal age.


will change as indicated below


In this section you and your refer to the policy owner11.0 Billing information

Will the billing information for the existing policy change?

How will your regular premiums for the existing policy be paid?

For universal life or Performax Gold policies only

If you are paying by cheque, the cheque must be in Canadian funds drawn on a Canadian bank or financial institution and made payable to Manulife. We do not accept cash. Specify the initial or future deposit allocation on the product page or financial change form. Otherwise, we will set it as savings.

This change will be processed on the monthly processing day following the date that all our requirements regarding policy splitting are met.

Complete the following account holder information if any payor or joint bank account holder is not one of the above:

Account holder #1

Who will be paying your regular premiums for the existing policy?

Name (first, middle initial, last) or full legal name of corporation, including Company, Limited, Inc., etc.

Address (street and number)

City or town Province

Postal code Relationship to policy owner

$

Your regular payments

Owner #1

annually, by cheque go to section 12.2

will not change

calculate the minimum payment OR

the total planned deposit is

If an account holder is not the policy owner or one of the people to be insured under the policy, they must sign in section 14.1 to authorize the withdrawals.

will change as indicated on Set up or change a pre-authorized debit plan, NN0312E

Owner #2

Person A to be insured

Person B to be insured

Account holder #1Name (first, middle initial, last) or full legal name of corporation, including Company, Limited, Inc., etc.


City or town

Province Postal code



City or town Province

Postal code Relationship to policy owner



City or town

Province Postal code

semi-annually, by cheque go to section 12.2

quarterly, by cheque go to section 12.2monthly by pre-authorized debit (if selected, tell us the following information)

annually, by cheque go to section 12.2

semi-annually, by cheque go to section 12.2

quarterly, by cheque go to section 12.2monthly by pre-authorized debit (if selected, tell us the following information)

How will your regular premiums for the new policy be paid?

will change as indicated below

Will the billing information for the new policy change?

Who will be paying your regular premiums for the new policy ?

Owner #1

will not change

will change as indicated on Set up or change a pre-authorized debit plan, NN0312E

Owner #2

Person A to be insured

Person B to be insured


For universal life or Performax Gold policies only

$

calculate the minimum payment OR

the total planned deposit is


11.0 Billing information (continued)

Your regular payments (continued)

The withdrawal date must be at least 4 days prior to the monthly processing date.


Request for monthly pre-authorized debit plan

add this monthly pre-authorized debit to an existing monthly pre-authorized debit plan with us

Request for monthly pre-authorized debit plan

Policy number on which the current monthly pre-authorized debit plan is set up

add this monthly pre-authorized debit to an existing monthly pre-authorized debit plan with usPolicy number on which the current monthly pre-authorized debit plan is set up

OR OR

set up a new monthly pre-authorized debit plan using the banking information below. Withdrawal date for monthly pre-authorized debit

(1st through 28th)

set up a new monthly pre-authorized debit plan using the banking information below. Withdrawal date for monthly pre-authorized debit

(1st through 28th)

What banking information should we use?

from the attached void cheque (Attach the cheque to this page.)

What banking information should we use?

from the attached void cheque (Attach the cheque to this page.)

as follows: (Only complete the table below if you donot have a void cheque.)

as follows: (Only complete the table below if you donot have a void cheque.)

Name of Canadian bank or financial institution

Transit number Institution number

Account number

Name of Canadian bank or financial institution

Transit number Institution number

Account number

11.1 Direct deposit for refunds

Transit number Institution number Account number

MEMO

WATERLOO, ONTARIO N2J 4C6

The illustration shows the MICR encoding used onstandard cheques. The labels help you identify thecodes to enter.

Bank500 KING ST. NORTH

If this policy split produces a refund, deposit it to: the bank account recorded in your insurance file for policy numberthis bank account shown on the attached void cheque: account number

12.0 Authorizations Authorizations include authorization and certification for billing information, and authorizations and consent required by the new owner

In this section you and your refer to the owner(s) of the bank account from which withdrawals will be made.

Pre-authorized debits

Authorizing variable amount monthly pre-authorized debits to make your subsequent paymentsIf you have asked us to establish a monthly pre-authorized debit plan to pay your regular premiums, you agree to the following:

• you authorize us to make monthly withdrawals from your bank account to pay for the policy• except as otherwise stated in this agreement, the withdrawals will occur on the date that you

specified above

• the withdrawals from your bank account are in variable amounts. This means they may increase as required to administer the policy. (Example: if the premiums for the policy are scheduled to change),

• if you have a policy with insufficient account value to cover the monthly deduction, we will not increase the payments withdrawn from your bank account to prevent your policy from terminating, and

• you waive the right to receive 10 days’ notice of the amount and date of each monthly pre-authorized debit to be made from your account.

The pre-authorized debit for your monthly payments will be treated as a personal pre-authorized debit (PAD) as defined by Payments Canada in Rule H1 at www.payments.ca.

Variable amount monthly pre-authorized debits for subsequent payments

12.1 Billing information and certification

What we will do if your bank or financial institution does not honour a monthly pre-authorized debitIf your bank or financial institution does not honour a monthly pre-authorized debit the first time we present it for payment, we may attempt to withdraw that payment again within 30 days.

If that withdrawal is not honoured, we may attempt to withdraw that amount again together with your next month’s monthly pre-authorized debit.We reserve the right to end the monthly pre-authorized debit plan immediately if a withdrawal is not honoured.

Monthly pre-authorized debit plan


Authorizing pre-authorized debits from your bank accountIf the owner or the insured person is paying the premiums, their signature in section 14.0 means that they have read and agree to the authorizations in this section. They do not have to sign in this section.By asking us to take payments from your bank account, you agree that you have read and agree to the following information.

Making changes to your monthly pre-authorized debit planYou can request changes to the amount of the monthly pre-authorized debit or the account from which the monthly pre-authorized debit is being taken by telephone or in writing. We must receive the request at least three days before the monthly pre-authorized debit date. The advisor for this policy can also make these changes on your behalf.

Universal life or Performax Gold policiesFor universal life or Performax Gold policies, we have the right to change your monthly pre-authorized debit date to be at least four days before your policy processing day.

Personal withdrawalsAll monthly pre-authorized debits from your bank account will be treated as personal withdrawals as defined by Payments Canada in Rule H1 at www.payments.ca.

Cancelling this agreementYou or we can end this agreement at any time by giving 10 days’ written notice, counted from the date the notice is mailed. For a sample cancellation form or more information about cancelling a monthly pre-authorized debit plan, contact your bank or financial institution or visit www.payments.ca.

Unauthorized withdrawalsYou have certain recourse rights if any withdrawal does not comply with this agreement. For example, you have the right to receive reimbursement for any withdrawal that is not authorized or is not consistent with this agreement. To obtain more information on your recourse rights, contact your bank or financial institution or visit www.payments.ca.

Your personal informationYou authorize us to collect, use, release and exchange any personal information necessary to fulfill any obligations relating to withdrawals made from your bank account.For more information about withdrawals from your bank accountIf you have any questions or concerns about withdrawals from your bank account, contact us at 1-888-626-8543 in all provinces except Quebec and at 1-888-626-8843 in Quebec.For more information about your rights, contact your bank or financial institution or Payments Canada at www.payments.ca.CertificationYou certify that all people whose signatures are required on this account have signed in sections 14.0 and 14.1, including any required joint account holders or corporate signing officers.• If an account holder is the policy owner or one of the people to be insured under the policy, their

signature in section 14.0 is authorization for monthly pre-authorized debits.• If an account holder is not the policy owner or one of the people to be insured under the policy, they must

sign below to authorize the withdrawals in section 14.1.• If withdrawals are to be made from a joint account, both account holders must sign if your bank or

financial institution requires both signatures.• If withdrawals are to be made from a corporate account, identify the corporate account and provide the

signatures and titles of two corporate signing officers or the signature and title of one signing officer and the corporate seal. If the corporation does not have a corporate seal and you are the only person authorized to sign on behalf of the corporation, sign in the box for account holder #1 and write your initials in the box provided.

12.1 Billing information and certification (continued)

12.2 Authorizations and consent required by the new owner

For owners of the existing policy, authorizations and consent provided in the original application remain in effect.

In this statement, you and your refer to the policy owner or holder of rights under the policy, the life insured, and the parent or guardian (tutor, in Quebec) of any child named as life insured who is under the age of 16 (or under 18 in Quebec). We, us, our, and the Company refer to The Manufacturers Life Insurance Company, and our affiliated companies and subsidiaries. Updates to this statement and further information about our privacy practices are posted to www.manulife.ca.We collect, use, verify and disclose your personal information for identified purposes, and only with your consent, or as permitted or required by law. By signing the application, you give your consent for us to collect, use, and disclose your personal information, as set out in this statement. Any alterations to the consent must be agreed to in writing by the Company.What personal information do we collect?Depending on the product you have applied for, we collect specific personal information about you such as:• identifying information such as your name, address, telephone number(s), email address, your

date of birth, driver’s license, passport number or your Social Insurance Number (SIN)• information about how you use our products and services, and information about your

preferences, demographics, and interests• other personal information we may require to administer our business relationship with you.We use fair and lawful means to collect your personal information.Where do we collect your personal information from?We collect your personal information from:• your completed applications and forms• other interactions between you and the Company,• other sources, such as:

• your advisor or authorized representative(s)• third parties with whom we deal in issuing and administering your policy now and in the future• public sources, such as government agencies or internet sites.

What do we use your personal information for?We will use your personal information to:• help us properly administer the products and services that we provide, and to manage our

relationship with you• confirm your identity and the accuracy of the information you provide• evaluate your application, and issue and administer the rights under the contract• comply with legal and regulatory requirements• understand more about you and how you like to do business with us• analyze data to help us understand our customers better, so we can improve the products and

services we provide• determine your eligibility for, and provide you with details of, other products or services that may

be of interest to you.


Withdrawing your consentYou may withdraw your consent for us to use your SIN or Business Number, if applicable, for non-tax administration purposes. You may also withdraw your consent for us to use your personal information to provide you with other service or product offerings, excluding those mailed with your statements.You may not withdraw your consent for us to collect, use, retain or disclose personal information we need to issue or administer the policy unless federal or provincial laws give you this right. If you do so, a policy may not be issued and benefits will not be payable under the policy or we may treat your withdrawal of consent as a request to terminate the policy.If you wish to withdraw your consent, phone our customer care centre at 1-888-MANULIFE (626-8543), or 1-888-MANUVIE (626-8843) in Quebec, or write to the Privacy Officer at the address below.

Who do we disclose your personal information to?We disclose your information to:• persons, financial institutions and other parties with whom we deal in issuing and administering

your contract now and in the future• authorized employees, agents and representatives• your advisor and any agency which has entered into an agreement with us and has supervisory

authority, directly or indirectly, over your advisor, and their employees• any person or organization to whom you gave consent• people who are legally authorized to view your personal information• service providers who require this information to perform their services for us (for example data

processing, programming, data storage, market research, printing and distribution services and investigative agencies).

The abovementioned people, organizations and service providers are both within Canada and jurisdictions outside Canada, and would therefore be subject to the laws of those jurisdictions.Where personal information is provided to our service providers, we require them to protect the information in a manner that is consistent with our privacy policies and practices.How long do we keep your information?The longer of:• the time period required by law and by guidelines set for the financial services industry, or• the time period required to administer the products and services we provide.

Accuracy and AccessYou will notify us of any change to your contact information. You have the right to access and verify your personal information maintained in our files, and to request any factually inaccurate personal information be corrected, if appropriate. If you have a question, a concern, or wish to receive more information about parties who have access to your information or about our privacy policies and procedures, and/or wish to review your personal information in our files or correct any inaccuracies, you may send a written request to:

Opting out of direct marketingYou have the right to opt out of additional product offerings. By withdrawing your consent for us to use your personal information for the purpose of marketing, you understand it will not affect our ability to continue to provide you with the products and services you have requested, but it will exclude you from receiving direct personalized marketing or special offers on other products and services.

12.2 Authorizations and consent required by the new owner (continued)

Please note the security of email communication cannot be guaranteed. Do not send us information of a private or confidential nature by email. By contacting us via email you are authorizing us to communicate with you by email.

How we resolve complaintsTo discuss any questions or concerns you may have, please contact your advisor or our head office at:

1-888-626-8543 in all provinces except Quebec or 1-888-626-8843 in QuebecMore information about our complaint resolution process is available on the Internet at www.manulife.ca under Contact Us > Complaint resolution.


Privacy OfficerManulife500 King Street NWaterloo, ON N2J [email protected]

13.0 Acknowledgements AcknowledgementsIn this section, you and your refer to all of the people required to sign on the next page, in connection with either the existing policy or the new policy.We, us and our refer to The Manufacturers Life Insurance Company.The existing policy refers to the policy that is to be split as a result of this request to split.The new policy refers to any insurance issued as a result of this request to split.

Our approval of your request to change an insurance coverage and/or to split an insurance policy is subject to our current administrative rules. By signing on in section 14.0 you confirm that you have read and understood the completed application pages 1 – 19, including all of the following statements:• consent to the changes and deletions to the policy identified in section 1.0 and/or the splitting of the

policy identified in section 1.0 and all transactions as described in this completed form, and• authorize and consent to the points below that apply to you:

• within two years of the later of (i) the issue date of the existing policy, (ii) the latest reinstatement date of the existing policy or (iii) the date of any increase in coverage under the existing policy, we can void the new policy(ies) or change in coverage, if we relied on a material misrepresentation to issue the existing policy, reinstate it, or add coverage to it. After that time, we can void the new policy(ies) if there was fraud in relation to the application for the existing policy or any reinstatement or increase in coverage

• information collected as part of your original application forms part of the existing and the new policy and information collected on this form will be part of both policies

• insurance under the new policy(ies) will become effective on the date those policies are issued by us or the new insurer(s), provided all people to be insured under the new policy(ies) are alive on the date of issue. If the new policy(ies) take effect:• for life or critical illness insurance policies, the insurance on the existing policy is reduced

by the amount of insurance under the new policy(ies). The effective date of the reduction in the existing policy’s coverage is the date before the new policy(ies) become effective

• for long term care policies, all coverages on the existing policy except the Return of Premium on Death (ROPD) Rider are split equally between the existing and the new policy. The effective date of the reduced coverage in the existing policy is the date before the new policy becomes effective. The new policy will have the same Policy Date as the existing policy, and each coverage on the new policy will have the same Coverage Date and Coverage Issue Date as on the original policy

• splitting a life insurance policy may have tax implications, which may include increasing taxable income if you also transfer the ownership of the policy

• you (the owners, insured people, beneficiaries and creditors of the existing policy) authorize us to release all information connected with the existing policy to the new insurer(s). You authorize the new insurer(s) and any applicable reinsurers to use and disclose that information to issue and administer the new insurance policies and any claims associated with them

• we may contest the validity of the new policy(ies) based upon any information which could have been used to contest the validity of the existing policy if it had not been split. This includes any information provided to us at the time of application for or underwriting of the existing policy or any predecessor policy. This also includes information provided to obtain additional coverage or to modify or reinstate these policies

• the rights to terminate coverage described above do not limit our rights to void the new policy(ies) based on misstatement as described in the new policy(ies)

• you, any irrevocable beneficiary and any collateral assignee or hypothecary creditor understand that the changes may change the amount, timing and conditions under which benefits will become payable on your policy

• you, the insured person, any irrevocable beneficiary and collateral assignee or hypothecary creditor agree that a faxed copy of this form is valid authorization to process these changes

• we will not be bound by any collateral assignment, or hypothec in Quebec, with respect to the new policy(ies) until the new insurer(s) receives notice of the assignment or hypothec at its Head Office for Canada

• any coverages that will not remain on the existing policy and that will not be attached to a new policy must be terminated. If instructions regarding specific coverages or riders under the existing policy have not been provided in this form, we will terminate those coverages or riders and this form will become part of the policy identified in section 1.0 and/or section 2.0 and the new policy.

The Income Tax Act (Canada) introduced new tax rules for life insurance policies that were effective January 1, 2017. The new policy may be subject to the new tax rules. Under the new tax rules, your new policy may not allow you to make the same level of additional payments or deposits as your original policy. Talk to your advisor and be sure you understand the tax consequences of any change to your policy.

All policies


13.0 Acknowledgements (continued)

14.0 Signatures

Long term care policies only

For long term care insurance policies only:• when you split a shared LivingCare policy, you lose all benefits under the ROPD Rider. The ROPD Rider

is terminated and you cannot add this rider on either the existing or the new policy• if an Inflation Protection Rider was associated with the original shared coverages, that will continue

on both the existing and the new policy• as of the effective date of the policy split, the existing policy’s total amount of insurance and total

Benefit Balance are split evenly between the existing and the new policy.

Signatures required for the existing policyPersons insured under existing policy

By signing below, for policies issued in Quebec you also consent to the change of ownership for the existing or the new policy to a new owner identified in section 5.

Sign below and on next page

* If the owner is a corporation, we require:• the signatures and titles of two

signing officersor• the signature and title of one

signing officer and the corporate seal.

if the corporation does not have a seal and you are the only person authorized to sign on behalf of the corporation, in addition to signing, write your initials in the box provided.

** If the current beneficiary is an irrevocable beneficiary or a preferred beneficiary, he or she must sign the form to agree to the transfer of ownership and/or the beneficiary change and to release his or her interest as a beneficiary.

*** If the policy has been collaterally assigned or in Quebec, hypothecated, please either:• obtain a Release of Assignment

or Release of Hypothecation; or

• have the collateral assignee or hypothecary creditor sign where indicated to show consent for the policy split.

If the policy is assigned to a bank, we also require a Release of interest on bank letterhead with one or more signatures, and:• the signatures and titles of two

bank officials and the name of the bank, or

• the signature and title of one bank official and the bank seal.

Signature of person insured under the existing policy

Title

Signature of person insured under the existing policy

Title

Signature of witness


Date (dd/mmm/yyyy)

Date (dd/mmm/yyyy)

Signature of original owner of the existing policy (if not one of the insureds)*

Title


Date (dd/mmm/yyyy)

Initial here Write your initials here to confirm that you are the only person authorized to sign on behalf of the corporation and that it does not have a seal. You must also sign above.

Signature of original owner of the existing policy (if not one of the insureds)*

Title


Date (dd/mmm/yyyy)

Signature of new owner of the existing policy (if not one of the insureds)*

Title


Date (dd/mmm/yyyy)


Signature of new owner of the existing policy (if not one of the insureds)*

Title


Date (dd/mmm/yyyy)

Signature of irrevocable or preferred beneficiary on the existing policy**

Title


Date (dd/mmm/yyyy)

Signature of collateral assignee/hypothecary creditor on existing policy***

Title


Date (dd/mmm/yyyy)


Signature of collateral assignee/hypothecary creditor on existing policy***

Title


Date (dd/mmm/yyyy)


Original owners of existing policy

New owners of existing policy (only if applicable)

Other signatures required for existing policy

Signatures required for the new policy

Signature and title of the owner(s) of the new policy*

Title


Date (dd/mmm/yyyy)


Signature and title of the owner(s) of the new policy*

Title


Date (dd/mmm/yyyy)

14.0 Signatures (continued)* If the owner is a corporation,

we require:• the signatures and titles of

two signing officersor• the signature and title of one

signing officer and the corporate seal.

if the corporation does not have a seal and you are the only person authorized to sign on behalf of the corporation, in addition to signing, write your initials in the box provided.

14.1 Additional signatures for banking information

15.0 Advisor’s statement

Additional signatures may be required if you have changed your banking information.


If you have changed your banking information, sign here only if you are:• a corporate signing officer, or• not a policy owner or person insured under this policy

Existing policy New policyName of account holder #1 or corporate signing officer #1(first, middle initial, last)

Signature of account holder #1 or corporate signing officer #1

Title (if applicable) Date (dd/mmm/yyyy)

Name of account holder #1 or corporate signing officer #1(first, middle initial, last)




Initial here







In this section, you and your refer to the advisor. List the advisors involved in this application for change.If the servicing advisor shown is not the original servicing advisor, we will update our records to use theservicing advisor shown below.Name of servicing advisor # 1 (first, middle initial, last) Name of servicing advisor # 2 (first, middle initial, last)

Advisor code Branch code Commission share

%

Advisor code Branch code Commission share

%

By signing below, you confirm:• you hold all necessary licenses and certificates to write this application for change in your jurisdiction

and the jurisdiction where the policy owner resides,• if this change involves replacing another policy, you have made all proper disclosures to your client and

completed the appropriate replacement documents, and provided these documents to us, if necessary,• you have disclosed the following information to the owner of this policy:

• the name of the company or companies you represent,• you receive commissions for the sale of life and living benefits insurance products and may receive

bonuses, invitations to conferences or other incentives, and• any conflicts of interest you may have with respect to this transaction.

Name of advisor (first, middle initial, last) Advisor code

Signature of advisor

Email address or telephone number for advisor

Write your initials here to confirm that you are the only person authorized to sign on behalf of the corporation and that it does not have a seal. You must also sign above.

nn0943e - request to split an individual insurance policy · ♦ use this form to request a policy...

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