IP416 - Transamerica Life Canada

FINANCIAL SERVICE FORM
(for Existing Policyholders Only)
IP416 1/11

Financial Service Form
(for Existing Policyholders Only)
5000 Yonge Street
Toronto, ON M2N 7J8
www.transamerica.ca
1-800-797-2643
In this form, the terms “you, “your” and “owner” refer to the person who has policyholder’s rights under the contract. The term “we” refers to Transamerica Life Canada.
1. CONTRACT DETAILS
Name of Owner:
Policy Number:
This section must be completed in full.
Social Insurance Number:
Joint Owner’s Name (if applicable):
Irrevocable Beneficiary’s Name (if applicable):
Annuitant Name (if other than Owner):
2. PLAN TYPE
❍ Non-Registered ❍ TFSA ❍ LRSP/LIRA/RLSP ❍ RSP/Spousal RSP ❍ RIF/LIF/PRIF/LRIF/RLIF
3. DEPOSITS/
TRANSFERS-IN
Please complete section 8 with
deposit allocation instructions.
4. SURRENDERS/
TRANSFERS-OUT
Please complete section 8 with
surrender allocation instructions
Declaration accompanying
application for Lump-Sum Payment
of Locked-in Monies
5. SYSTEMATIC PLANS
6. PRE-AUTHORIZED
CONTRIBUTION PLAN (PAC)
If owner and payor are not the same
person, the payor needs to complete
form IP1308 (PAC Authorization form).
Not applicable to LIRA, LRSPs, RIFs,
LIFs, PRIFs, RLSPs, RLIFs, or Harvest
contracts.
For Five for Live contracts: The minimum
amount for a PAC is $100 ($50 per fund).
For Transamerica GIF, imaxxGIF, TIP, and
GIA contracts: The minimum amount for
a PAC is $50 ($25 per fund).
You understand that the PAC will not
take effect unless a personalized
pre-printed void cheque has been
provided.
The cheque must identify the financial
institution, branch, and account number
specified as the PAC (PAC Account).
$ __________________________ ❍ Top up only
❍ Cheque payable to Transamerica Life Canada
❍ Transfer from another institution__________
❍ Full
❍ Maturity Benefit Value
❍ Partial
❍ Maturity Top up only
❍ Gross
$ ____________________________ ❍ Net
❍ Pre-Authorized Chequing (PAC) - Complete sections 6,7 and 8
❍ Transfer from another Transamerica Policy: _______________________________
❍ Maturity Date: __________________ (instructions to be processed on this date if rec’d prior to)
❍ Cheque sent to address on file
❍ Cheque sent to Distributor/Broker
❍ EFT (Segregated Fund Policies Only - Not available for GIA/DIA or IMS)
With regards to redemption requests for locked-in monies under: (1) Small Amounts provision, (2) Financial Hardship, (3) Shortened Life Expectancy,
please note that each province/federal jurisdiction has specific pension laws and forms regarding withdrawals from locked-in accounts. Not all
jurisdictions may offer the listed withdrawal types.
❍ Change existing information
❍ Systematic Withdrawal (SWP) - Complete sections 7 and 8 ❍ Dollar Cost Averaging (DCA) - Complete section 10
You hereby authorize Transamerica to draw on the account at the financial institution which is identified on the attached void cheque (PAC Account)
in the amount and frequency indicated in Section 7 for the purpose of making deposits to the indicated Policy. For the purpose of this authorization,
you agree that all pre-authorized debits will be treated as personal. You waive the right to receive prior notice of the date the first PAC will
be withdrawn. You warrant that all required signatures for the authorization of debits for the PAC Account are present in this Authorization. You
certify that the banking information provided with respect to the PAC Account is accurate. You will provide Transamerica with a new void cheque if
the PAC Account is changed (must be received at least 10 days before the draw date). You consent to the disclosure of any personal information
contained in this Authorization to any third parties for the purpose of processing the PAC. You also understand and agree to all the terms and
conditions on this form.
Cancellation of PAC - This Authorization is continuing, except that you may cancel this Authorization at any time by giving Transamerica at least
10 days notice in writing. You may obtain a cancellation form by contacting your financial institution or at www.cdnpay.ca.
Cancellation of Right to Pay by PAC - Transamerica may cancel your right to pay by PAC:
(a) immediately if any PAC is not honoured by your financial institution because of insufficient funds in your account or for any other reason
preventing the transfer of funds; or
(b) on 10 days written notice to you.
The rights under the Policy are not affected by the cancellation of the PAC Authorization or the Cancellation of the Right to Pay by PAC.
You have certain recourse rights if any debit does not comply with this authorization. For example, you have the right to receive reimbursement for
any debit that is not authorized or is not consistent with this PAC Authorization. To obtain more information on your recourse rights, contact your
financial institution or visit www.cdnpay.ca.
Payor(s) Bank Account :
❍ Chequing ❍ Savings
PERSONALIZED PRE-PRINTED VOID CHEQUE REQUIRED
7. SYSTEMATIC PLAN
INFORMATION
PAC frequency for GIA accounts can only
be monthly, quarterly, semi-annually, or
annually and can only be drawn on the
7th, 14th, 21st, or 28th of the month.
All payments specified will be treated as
gross.
If the plan's draw/payment date falls on a
non-business day, the PAC/SWP will be
transacted on the next valuation date
following that day.
If Custom Payments are selected, the
amount must be greater than the RRIF
Minimum Payment, and, for LIF/RLIF
policies, less than the LIF/RLIFMaximum.
Please complete section 8 with allocation
instructions.
Frequency: ❍ Weekly ❍ Monthly ❍ Annually
❍ Bi-weekly ❍ Quarterly ❍ Semi-annually
Effective Date - Commence this plan on (1st to 28th of month):
DD/MM/YYYY:
For Systematic Withdrawal Plan (SWP):
Paymount Amount:
❍ RIF, LIF, PRIF, LRIF, RLIF - Minimum
TOTAL AMOUNT: $
Tax Witholding:
❍ Minimum
❍ The annual Guaranteed Lifetime Withdrawal Amount (GLWA) ❍ Client Specified Percentage: ______________% Federal
❍ LIF, LRIF, RLIF Maximum ❍ Custom Payments ______________% Prov (Quebec Only)
Transamerica Life Canada • Copy 1: Head Office Copy 2: Advisor Copy 3: Dealer/G.A. Copy 4: Client
*FRM-IP416*
IP416 1/11

8. DEPOSIT/SURRENDER
ALLOCATION
Indicate the fund name, fund code, sales
charge option, and the amount either by
$ or by %, NOT both.
You cannot mix different guarantee
options in the same policy.
GROWSafe 2 Maturity Instructions:
Top up may be reallocated into No Load
or DSC funds. Allocation to DSC Fund(s)
will be treated as a new deposit and
begin a new DSC schedule.
For GIA/DIA policies:
Indicate interest rate only if interest rate
guarantee was requested.
9. RESET OPTION
Not applicable to Transamerica GIF,
imaxxGIF, Five for Life, IMS RRIF, ELAP,
BIG, Seg 1, Agent's Plan, Money market
policies.
10. TRANSFER BETWEEN FUNDS
IMS Fund Based Policies: A transfer is
treated as a withdrawal from one fund
and a deposit into another fund. This
transaction impacts death and
maturity guarantees as the value of
units surrendered or acquired depends
on the market value on the date the
transfer is exercised, and extends the
premium maturity date to 10 years from
the effective date of the transfer.
Market value at maturity can only be
reallocated to funds under the same load
structure.
GROWSafe 2 maturity top up transfers
from No Load to DSC after a deposit
Maturity Date will be treated as a
withdrawal from the No Load fund and a
deposit to the DSC fund. This transaction
impacts death and maturity guarantees
and may have an impact on future
deposit maturity dates.
Please see the appropriate Summary Fact
Statements booklet for the investment
objective, policy restrictions, and risks
applicable to each Fund.
11. CLIENT AUTHORIZATION
Fund Fact pages are available on
www.transamerica.ca or on request
by calling 1-800-797-2643.
12. LICENSED AGENT
INFORMATION
* If a “Limited Power Of Attorney / Letter
of Authorization” (LPOA/LOA) is on file
with Transamerica, the owner's signature
is not required, but the advisor's
signature is required, provided that such
LPOA/LOA has not been revoked or
superceded.
LPOA is only applicable to purchases,
resets, and fund switches.
13. SPECIAL INSTRUCTIONS
AMOUNT SALES CHARGE OPTION
WIRE ORDER
FUND NAME FUND CODE PAC AMOUNT ($)
($ OR %) DSC ISC (0-5%)
NUMBER
❍ Gross
❍ Net
❍ Gross
❍ Net
❍ Gross
❍ Net
❍ Gross
❍ Net
❍ Gross
❍ Net
AMOUNT DEPOSIT TERM (YRS) REDEEMABLE/NON-REDEEMABLE INTEREST RATE
❍ Redeemable
❍ Redeemable
❍ Non-redeemable
❍ Non-redeemable
❍ Please accept this authorization to exercise the RESET Option for the value of the above contract on the date this request is received by
Head Office.
Resets are NOT allowed in the closing decade.
❍ Funds Switch
FROM TO
❍ $ FROM AMOUNT ❍% FUND FUND ❍ $ TO AMOUNT ❍%
CODE CODE
GUARANTEE OPTION
(75% OR 100%) IMS ONLY*
If the fund you are transferring from has a PAC or SWP plan, do you want to apply it to the fund you are transferring to ❍ Yes
* Complete only for existing IMS III policies with fund based guarantee (issued after January 1998).
SALES CHARGE %
(INITIAL SALES CHARGE ONLY)
By signing this form, you authorize Transamerica Life Canada to purchase, surrender, switch/transfer funds, or reset the Guaranteed
Base Value on your policy as indicated in the above/previous sections. You also acknowledge that your advisor has reviewed with you
the Fund Fact pages for each of the funds selected for Deposit allocation in section 8 and you have received a copy of this Authorization.
Signature of Policy Owner
✗
Date:
(DD/MM/YYYY):
Signature of Joint Owner (if applicable) or Spouse's signature for locked-in plans (if applicable) Date:
(DD/MM/YYYY):
✗
Signature of Irrevocable Beneficiary (If applicable)
✗
Dealer/GA Code:
Name of Advisor:
Rep/SA Code:
Date:
(DD/MM/YYYY):
❍ LPOA on file*
By signing this form, I confirm that I have reviewed with my client(s) the Fund Fact pages for each of the funds selected for Deposit allocation in section 8 above.
Signature of Advisor:
Date
(DD/MM/YYYY):
✗
❍ Re-allocation of MV at deposit maturity
❍ Internal Transfer from policy # ________________________________ deposit into policy # ______________________________________________________
❍ No
Transamerica Life Canada • Copy 1: Head Office Copy 2: Advisor Copy 3: Dealer/G.A. Copy 4: Client

5000 Yonge Street
Toronto, Ontario M2N 7J8
www.transamerica.ca
®Transamerica and the pyramid design are registered trademarks of Transamerica Corporation.
Transamerica Life Canada is licenced to use such marks.
IP416 1/11