So far so good. Please answer the following two questions so we know which plans we can offer you.
1. Are you currently confined to a hospital or nursing home, or have you ever been diagnosed as having a terminal illness, Alzheimer's Disease, tested HIV positive or been advised that you have AIDS-related Conditions?
No Yes
2. During the past five (5) years, have you ever been treated for, or been diagnosed as having:
You qualify for Guaranteed pricing and all payment options, though benefits are limited to return of premium plus 6% interest for the first two years. For more information, please see the Terms & Conditions here .
Congratulations! You qualify for Preferred pricing and multiple payment options.
Which plan suits you best?
Cheapest Monthly Payment Plan 3 Year Payment Plan 5 Year Payment Plan 10 Year Payment Plan 15 Year Payment Plan 20 Year Payment Plan Single Pay Policy
The premium for your selected coverage is $ per month . It's a convenient . This provides guaranteed issue of a fully paid-up executor liability insurance policy for your estate with estimated value of $ , plus guidance, support and direction for your executor, providing protection, peace of mind and family harmony.
This is funded with $ of the proceeds of this policy. You have $ of optional coverage available for executor compensation and/or final expenses.
You qualify for a single pay policy, which ensures your executor will have guaranteed executor insurance coverage, guidance and direction.
Application
Just fill out a few more details to submit your application.
Email
Phone number
SIN
Occupation
Mailing Address
Address
City
Province
ON MB SK AB BC NB NL PE NS YT NT NU
Postal code (no spaces)
Physical Address (if different)
Address
City
Postal code (no spaces)
Executor DetailsThe Executors/Estate Administrators are person(s) named in a will by the Applicant to administer his/her estate and is/are the individual(s) who will be covered by the Estate Risk Protection Plan.
Number of Executors
Primary Executor Name
Relationship
Phone
Email
Address
City
Province
ON MB SK AB BC NB NL PE NS YT NT NU
Postal code (no spaces)
Payment
Select payment type (please note that credit card payment is not available for single pay)
Credit Card Cheque PAC
Payment term
Monthly Quarterly
PAC Date
PAC Account
Credit Card Type
Visa MasterCard
Credit Card Number
Exp (mmyy, please do not use a / between the month and year)
Security code
In name of
Applicant Owner Other
Certificate Owner InfoPremiums may be paid by cheque, PAC or Credit Card (Time Pay only). Check the frequency (M Q) and the payment period (Single, 3, 5, 10, 15, or 20 years).
If PAC is selected, indicate the day of the month subsequent/renewal premiums are to be drafted, indicate if the bank account is chequing or savings, and attach a void cheque to the Enrollment Form. This is not when the first premium will be drafted immediately, i.e. when the Enrollment Form is processed.
If payment is by Credit Card, check MasterCard or Visa, fill in the Credit Card number, expiry date and security code. Also indicate whether the credit card belongs to the Applicant, Owner or Other Payor (if “Other Payor”, complete Form 0058-12). Credit Card payment is not available with Single Pay options.
First name
Middle initial
Last name
Date of birth
Age
Gender
Woman Man Prefer not to say
SIN
Occupation
Relationship to applicant
Phone
Email
Address
City
Province
ON MB SK AB BC NB NL PE NS YT NT NU
Postal code (no spaces)
Does the certificate owner have power of attorney?
No Yes
Signature (type your name again):
Signed at: (please give city and province)
An agent assisted me with my application:
No Yes
Agent code
Signature (agent types name):
Your current total is: $
I understand that the coverage being applied for does not immediately purchase services or estate protection. It is used to purchase them at a later time. I hereby irrevocably assign as its interest may lie the Estate Services death benefit of the certificate applied for and to be issued to the Estate Risk Protection Plan Inc. to provide estate services and an estate protection policy for my executor/estate.
I agree to and understand the following: a) no coverage shall exist until the certificate is issued while the Applicant is living and the initial premium is paid; b) this certificate does not replace any insurance policy or annuity; c) I am enrolling as a member of the Association for Personal Resource Planning of Canada (APRP) to which Assurant group annuity plans are provided; d) my death benefit may be partially or entirely reduced in the event I misrepresented any material informa- tion on this enrollment for insurance; e) the personal information in this form will be kept secure and confidential and will not be disclosed except as permitted by law or at my signed request.
By completing this form, I acknowledge that Estate Risk Protection Plan Inc. will collect, use and disclose my personal information to third parties, including my lawyer, as necessary for underwriting purposes, to fulfill risk mitigation services, and to fulfill the contract in accordance with applicable legislation. Estate Risk Protection Plan Inc. will: a) not collect, use or disclose my personal information for any purpose other than those that they identify to me; b) keep my personal information only for as long as needed to fulfill the stated purpose or as required by law; c) maintain my personal information in as accurate, complete and up-to-date a form as possible; d) safeguard my personal information to the best of their ability; and e) respond to any request I may make to access or correct the personal information they hold about me.
In order to provide the best service and information for applicants, co-applicants, and executors, Estate Risk Protection Plan Inc. must request my consent to allow communication and to send important information and announcements. My signature below forms consent required to comply with the Anti-Scam Legislation CCASLl.
I have read and agree to the above
Signature (type your name again):
Signed at: (please give city and province)
Date signed (DD/MM/YYYY):