RBC Insurance Application

Application for Life Insurance to RBC Life Insurance Company

Page 1 - Proposed Life Insured A

1. First Name Middle Name Last Name Prefix

2. Gender Female Male Country of Birth Social Insurance Number Date of Birth Age as of Nearest Birthday

3. Citizenship Canadian Citizen Permanent Resident U.S. Citizen Other

4. Home Address

City Province Postal Code Phone Number

5. Employer Name Employer Address Phone Number

Nature of Business How long with this Employer? Professional Designation/Degree

Current Occupation Number of Years at this Occupation Former Occupation

Beneficiary – Proposed Life Insured A

Primary Beneficiary 1: First Name Middle Name Last Name Revocable Irrevocable Relationship % Share

Primary Beneficiary 2: First Name Middle Name Last Name Revocable Irrevocable Relationship % Share

Primary Beneficiary 3: First Name Middle Name Last Name Revocable Irrevocable Relationship % Share

Contingent Beneficiary: First Name Middle Name Last Name Relationship

Page 2 - Proposed Life Insured B

8. First Name Middle Name Last Name Prefix

9. Gender Female Male Country of Birth Social Insurance Number Date of Birth Age as of Nearest Birthday

10. Citizenship Canadian Citizen Permanent Resident U.S. Citizen Other

11. Is the home address the same as Proposed Life Insured A? Yes No If no, complete address below.

Home Address

City Province Postal Code Phone Number

Page 3 - Applicant/Owner

15. Owner Type Proposed Life Insured A Proposed Life Insured B Joint Other

First or Company Name Middle Name Last Name Prefix

SIN or Business Number Relationship to Proposed Life Insured A and B

Mailing Address

City Province Postal Code Attention

18. Language of Policy English French

Page 4 - Universal Life / Identity / Third Party

19. Individual identity document Place of Issue Document Number Country of Issue

20. Joint owner identity document Place of Issue Document Number Country of Issue

21. Entity document type

22. Is any Applicant/Owner applying on behalf of a third party? No Yes

Page 5 - Insurance Applied For

23. Plan Single Life Joint Last-to-Die Joint First-to-Die Non-Smoker Smoker

Face Amount $ Riders/Benefits

Universal Life death benefit option: Level Death Benefit with YRT Increasing Death Benefit with Level Cost Increasing Death Benefit with YRT Cost

Long Term Care Benefit? Yes No

24. Existing insurance in force/pending? Yes No

25. Conversion Existing policy number Full conversion? Yes Partial conversion? Yes Retain? Yes Cancel? Yes

Conversion details

Page 6 - Premium Payment

29. Initial Scheduled Premium $ Billing Frequency Annual Monthly PAC

PAC withdrawal date Initial premium to be drawn by PAC? Yes No

30. Pre-Authorized Chequing Agreement

Name of Bank or Financial Institution Transit Number Bank Number Account Number

Address

City Province Postal Code

Name of Payor (Account Holder) Name of Second Payor (if any)

Page 7 - Personal Information

Question 1(a) and 1(b) for Proposed Life Insured A and B: use the spaces below for Yes/No answers and details.

A Yes No B Yes No

Page 8 - Financial Information A

Main purpose of insurance Personal Income Replacement Estate Conservation Investment Credit Facility Other Business Buy/Sell Key Person Collateral

Source of planned premium

Annual earned income: Salary $ Commissions $ Bonuses $ Other $

Other income: Dividends $ Interest $ Other $ Source

Not currently working, source of income?

Page 9 - Financial Information B

Main purpose of insurance Personal Income Replacement Estate Conservation Investment Credit Facility Other Business Buy/Sell Key Person Collateral

Source of planned premium

Annual earned income: Salary $ Commissions $ Bonuses $ Other $

Other income: Dividends $ Interest $ Other $ Source

Not currently working, source of income?

Page 10 - Tobacco Usage

Proposed Life Insured A and B tobacco questions. Check Yes/No and provide quantity/frequency and date last used.

Page 11 - Child Term Rider

Child 1: First Name Middle Name Last Name Relationship Date of Birth Age

Gender Female Male Height Weight Units cm ft/in kg lbs

Page 12 - Medical History A

Height Weight

Weight changed in last year? Yes No Gained? Lost?

Page 13 - Medical History B

Height Weight

Weight changed in last year? Yes No Gained? Lost?

Page 14 - Medical History Continued

Page 17 - Temporary Life Insurance Application

Has Proposed Life Insured A Yes No Has Proposed Life Insured B Yes No

Dated at this day of year

Page 19 - Disclosure Statement / Notice

Page 21 - Authorization

Dated at this day of year

Page 23 - Declarations, Agreements and Consents

Dated at this day of year

Page 24 - Representative’s Report

How long have you known Proposed Life Insured A? Proposed Life Insured B?

Have you collected money? Yes No Amount collected $ Date received

Page 25 - Representative’s Supplementary Report / Checklist

Representative’s Name Company Marketing Office Share %

Checklist

Disclosure Statement for the Province of B.C. Medical Information Bureau’s Pre-Notice TIA receipt

Supplementary questionnaires Disclosure form Payment for first month Signed illustration Void cheque Initial Investment Allocation Form

Application checked by: Print Name Code Number Signature Telephone

Additional Notes