Perspecta Investment Loan Program with Standard Life (6152)

Policy Number Name of Life Insured
The Company is requested to:
Issue a policy loan (Note: the policy contract is not required.)
Amount of policy loan requested:
$ , or the maximum amount available, if less.
The maximum amount available.
Apply a policy loan as follows:
Application for
Policy Loan or Dividend
All right, title and interest in the policy is assigned to the company as sole security
for the repayment of the loan with interest, subject to the provisions of the policy.
Pay dividends on deposit in cash. (Not applicable to the Perspecta Investment Loan Program.)
Apply dividends on deposit as follows. (Not applicable to the Perspecta Investment Loan Program.)
Signature of policy owner Date
Signature of present benefi ciary, if required Date
Signature of collateral assignee (if any) Date
Request for pre-authorized loan repayment plan Policy number
I hereby request Standard Life to process withdrawals under its pre-authorized plan for the purpose of making loan payments and
I hereby authorize any bank or fi nancial institution with whom I have an account to process such withdrawals as though they were
signed by the undersigned.
1. By written notice either party may cancel this agreement. Payor client no.
2. This payment plan is subject to the provisions of the policy or policies.
Loan repayment amount $ Deposit day
Name of depositor as shown on bank records
Joint account – 2nd name
Head office use only
Date Signature of depositor
Date Signature of depositor
Note: a specimen void cheque must be attached. Note: for a joint account all depositors must sign this form.
PC BIL 2053B-06-2007
Current account
P.C.A.
Savings chequing account
Other (specify)
Standard Life 15