imaxxGIF Application - Transamerica Life Canada

Effective January 2014imaxx Guaranteed Investment FundsapplicationThis application is only available for transfers from an existing GROWSafe 94 or IMS I, II, and III Contractregistered as an RSP, LIRA or LRSP to an imaxxGIF Contract registered as a RIF, LIF, PRIF or RLIF.Highlighted sections are mandatory and must be completed.To apply for a:• Retirement Income Fund (RIF)• Life Income Fund (LIF)• Prescribed Retirement Income Fund (PRIF)• Restricted Life Income Fund (RLIF)

imaxxGIF Application Effective: January 2014Please print firmly. Any changes must be initialled by the Owner.Policy No. _______________________In this application, “you” and “your” mean the person who is theowner or holder of rights under the Contract. “We,” “our,” “us,”and “Transamerica” mean Transamerica Life Canada.1. plan typEPlease select one.†Available for Federal Plans only.m Retirement Income Fund (RIF)m Spousal RIFm Life Income Fund (LIF)m Prescribed Retirement Income Fund (PRIF)m Restricted Life Income Fund (RLIF) †For a LIF, PRIF or RLIF, the Contract is to be governed by the laws of: insert name of province ____________ or if Federal Plan“Canada,” as applicable.RRIF minimum calculation:m Qualifying (RRIFs opened prior to January 1, 1993)m Non-qualifying (RRIFs opened after December 31, 1992)2. NOMINEE INFORMATIONIf this policy is classified as a nomineeplan, the policy will be non-registeredat Transamerica.Is this a nominee plan?m Nom YesCross Reference #__________________________________ Type of registration with nominee ________________________________3. OWNER/annuitant INFORMATIONThe Owner must be a Canadian resident atthe time the application is completed.The Owner must also be the annuitant.ONLY ONE PERSON CAN BE THE ANNUITANTm Mr.m Mrs.m Ms.m Missm OtherLast Name First Name Initial(s)Street Address Apt Language Preferencem English m FrenchCity Province Postal Codem Malem FemaleSocial Insurance NumberOptional: Phone Number:Principal Business or Occupation:Date of BirthDD/MM/YYYYE-mail address:4. Spousal informationComplete if:• When legislation permits, the annualminimum payment is to be determinedbased on your spouse’s age in a RIF/LIF/LRIF/PRIF/RLIF contract. This electioncannot be changed, even on marriagebreakdown (e.g., separation, divorce)or the death of your spouse.m Mr.m Mrs.m Ms.m Missm Otherm Malem FemaleLast Name First Name Initial(s)Street AddressCity Province Postal CodeSocial Insurance NumberPrincipal Business or Occupation:Date of BirthDD/MM/YYYYApt5. SUCCESSOR ANNUItantINFORMatION (OPTIONAL)Only the spouse can be designated assuccessor annuitant.The successor annuitant takes theannuitant’s place upon the death of theannuitant named in Section 3. As a result,the policy continues. The death benefitis payable on the death of the annuitantor successor annuitant, whicheverhappens later.The successor acquires all the holder'srights upon the holder's death including theunconditional right to revoke any beneficiarydesignation made by the holder.m Mr.m Mrs.m Ms.m Missm Otherm Malem FemaleLast Name First Name Initial(s)Street AddressCity Province Postal CodeSocial Insurance NumberTransamerica Life Canada • Copy 1: Head Office Copy 2: Advisor Copy 3: Dealer/G.A. Copy 4: ClientDate of BirthDD/MM/YYYYApt*FRM-IP881*IP881 1/14

6. polITIcally EXPOSEDFOREIGN PERSONa) Is a premium and/or lump sum payment equal to or greater than $100,000 being made or to be made?m Yes m NoIf the answer is “Yes,” the proposed Owner must complete question (b)b) Do any of the persons described in section 3 or 4 above, or any person to whom you are related by blood or marriage (includingyour common law partner), hold, or have they held in the past, any of the following positions in a country other than Canada:head of state, member of the executive council of government or member of the legislature; deputy minister (or equivalent);ambassador or ambassador’s attaché or counsellor; military general (or higher rank); president of state-owned company or bank;judge or leader or president of a political party in a legislature?m Yes m NoIf the answer is “Yes,” the Politically Exposed Foreign Person Form (IP-LP1165) must be completed by that person.7. BENEFICIARY INFORMatIONThe death benefit will be paid to yourestate if no beneficiary is designated.If a beneficiary is designated irrevocably, theOwner cannot exercise certain contractualrights without the irrevocable beneficiary’sconsent. Minors named as irrevocablebeneficiaries cannot give such consent.For Quebec residents: If you name yourmarried or civil union spouse as beneficiary,this designation is irrevocable unless youspecifically indicate that the designationis revocable.A contingent beneficiary has no rights aslong as a primary beneficiary is living.For contracts classified as a nomineename contract:If the plan is a self-directed RRIF at thenominee dealer, the beneficiary must be“Trustee in trust for the named beneficiary ofthe plan, pursuant to the terms of the plan.”Last Name First Name Initial(s)Relationship to annuitant (relationship to Owner in Quebec) m Revocable Share of benefits m Primarym Irrevocable_____________% m ContingentLast Name First Name Initial(s)Relationship to annuitant (relationship to Owner in Quebec) m Revocable Share of benefits m Primarym Irrevocable_____________% m ContingentLast Name First Name Initial(s)Relationship to annuitant (relationship to Owner in Quebec) m Revocable Share of benefits m Primarym Irrevocable_____________% m ContingentTrustee for minor beneficiaries (except for Quebec)Last Name First Name Initial(s)Street AddressAptCity Province Postal CodeRelationship to minor _________________________________________Date of BirthDD/MM/YYYY8. LUMP SUM DEPOSIT/ TRANSFERFROM OTHER INSTITUTION(S) ORINTERNAL TRANSFERAttach copies of transfer documentation.The advisor must forward all originals tothe transferring financial institution.The amount transferred is an estimation.The actual amount(s) will be specified onthe confirmation notice(s). In the caseof an internal transfer from an existingcontract, please specify the Transamericapolicy number.Cheque made payable to Transamerica Life Canada $ __________________________Deposit(s) being transferred from other institutions:Type of Plan Transferring Institution or Internal Policy # Amount Being Transferred9. INVESTMENT INSTRUCTIONSIndicate the fund name, fund code, salescharge option and the initial investmentamount either by $ or % (NOT both)for each Fund.Fund Name Fund Code Wire OrderNumberInitial Investment($ or %)Sales Charge OptionDSC ISC (%)*Complete Section 12 for scheduledfund switches (dollar cost averaging).Deposits by transfer must state allocationby percentage only.*If no ISC % is specified the deposit will be processed at 0% ISC.Please refer to our fund code chart for a complete listing of funds and applicable fund codes.Transamerica Life Canada • Copy 1: Head Office Copy 2: Advisor Copy 3: Dealer/G.A. Copy 4: Client

10. Systematic WithdrawalPlan (SWP) and RIF/PRIF/LIF/RLIF Payment DetailsAll payments specified will betreated as gross. If the SWPdate falls on a weekend orholiday, the SWP will be drawnon the business day followingthe SWP date.If no frequency is selected, theSWP will be payable monthlyon the first business day ofeach month.For RIF, PRIF, LIF and RLIF plans,you are required to be paid theRIF minimum payment asprescribed by the Income Tax Act(Canada) commencing (at anytime) in the second calendar yearof your contract.If Level/Custom Payments areselected, the amount selectedmust be greater than the RIFMinimum Payment, and forLIF/RLIF contracts, less than theLIF/RLIF Maximum. (Payments inthe first year are fully taxable.)Note: Withdrawal date is the datethe units are redeemed from yourpolicy. Payment will be sent thenext business day. Direct Depositmay take 2-3 days depending onwhen your financial institutionprocesses the transfer of funds.FREQUENCY and PAYMENT DATE (For SWP, RIF, LIF, PRIF & RLIF):First withdrawal date (l st to 28 th of month):DD/MM/YYYYFrequency:m Monthly m Quarterly m Semi-Annually m AnnuallyRIF/PRIF/LIF Payment:Scheduled Payment Option: (Please select only one)m RIF/PRIF/LIF/RLIF Minimum m Qualifying or m Non-qualifyingm LIF/RLIF Maximumm Level/Custom – client specified amount of: $ _____________________Tax Withholding (for RIF/PRIF/LIF/RLIF):m Minimum m Client specified percentage. Federal _______________ %, Provincial (Quebec Residents Only) _______________ %.Payment Method:PLEASE ATTACH PERSONALIZED PRE-PRINTED VOID CHEQUEm Cheque m Direct DepositWe will deposit scheduled payments directly to your bank accountRIF/PRIF/LIF/RLIF Payments:m I hereby elect:m I do not elect:To use my spouse’s date of birth to determine the minimum amount of the periodic payments under the RIF/LIF/RLIF. My spouse’sdate of birth is indicated in Section 4. This election cannot be changed, even in the case of a marriage breakdown or the death of my spouse.Withdrawal Instructions:Fund Name Fund Code Amount or (%)$ %$ %$ %$ %11. LIF/PRIF/RLIF informationFOR A LIF OR PRIF, DO YOU HAVE A SPOUSE WITHIN THE MEANING OF APPLICABLE PENSION LEGISLATION?m No m Yes If “Yes,” please complete the information below.For British Columbia, Alberta, Saskatchewan and Manitoba, please attach a completed spousal consent or waiver form.For Ontario, Newfoundland & Labrador, Nova Scotia and Federal (includes Yukon, NWT and Nunavut), your spouse must signbelow to indicate his or her consent to purchase the LIF.Signature of spouse: ________________________________________Date: DD/MM/YYYYCOMMUTED VALUE OF PENSION BENEFIT (Applicable if the source of the deposit is Ontario, Saskatchewan, Nova Scotia,New Brunswick or Nfld/Lab. pension funds): Was the commuted value of the pension benefit which is being transferred to thispolicy determined in a manner that differentiates on the basis of sex? (Applicable to Saskatchewan LIRAs only if the assets weretransferred into the LIRA from a policy in existence before January 1, 1993.)m No m YesIf “Yes,” then state the portion of the pension benefit being transferred which was determined in a manner which sodifferentiates __________ %*PENSION BENEFIT CREDIT (Applicable if the source of the deposit is Federal pension funds): Was the pension benefit creditwhich is being transferred to this policy varied according to the sex of the plan member?m No m YesIf “Yes,” then state the portion of the pension benefit credit being transferred which is so varied __________ %**If you do not know the answer to this question, a statement indicating the answer must be provided from the relevant pension plan administrator.12. Scheduled fundtransfers (Dollar CostAveraging Optional)Transfers between sales chargeoptions are not permitted as partof this service.m By checking here, you request that we make a transfer from the fund listed below to the other fund(s) of the same sales charge optionwithin the same policy on a scheduled basis.Start Date – Commence this plan on (1 st to 28 th of month):DD/MM/YYYYFrequency:m Monthly m Quarterly m Semi-Annually m AnnuallyScheduled Total Transfer of: $ ____________________________From FundTo FundFund Name Fund Code $ Amount Fund Name Fund Code $ AmountTransamerica Life Canada • Copy 1: Head Office Copy 2: Advisor Copy 3: Dealer/G.A. Copy 4: Client

13. owneracknowledgementand authorizationOwner and successor annuitantmust sign here.By signing below, you acknowledge receipt and review of the imaxx Guaranteed Investment Funds Information Folder (includingFund Facts) together with the Annuity Policy prior to signing the Application, confirm that you have read and agree to the terms andconditions at the back of this application, and consent to the use and verification of personal information for the purpose of issuingand administering the contract as described in this application. Fund Fact Pages are available on www.transamerica.ca or on request bycalling 1-800-797-2643.From time to time Transamerica may use your personal information to determine which other insurance and financial productsmay meet your needs and to offer such products to you. Transamerica may also disclose your personal information to its affiliatedcompanies for their use for such purposes. If you do not wish your personal information to be used for this purpose check here: mor you can write to us at: Transamerica Life Canada, 500 – 5000 Yonge St, Toronto, ON M2N 7J8, Attention: Privacy Officer.Signature of Owner: Date Signed: DD/MM/YYYY Province________________________________________________________________________________Signature of Successor Annuitant: Date Signed: DD/MM/YYYY Province________________________________________________________________________________14. Verificationof identityThis section, including thesub-section requesting if theOwners are applying for thepolicy on behalf of a thirdparty must be fully completedby a Licensed Agent.We are required to verifythe identity of the applicantpursuant to the Proceeds ofCrime (Money Laundering andTerrorist Financing) Act. Youmust view one originalnon-expired document producedby the Owner(s) to verify theiridentity as required by law.Social Insurance Number cardscannot be used to verify identity.Is the Owner applying for the policy on behalf of a third party?If yes, complete the Identity and Third Party Determination Form (IP-LP782).m Yesm NoOwnerm Driver’s Licencem Birth Certificatem Passportm Canadian Citizenshipm Age of Majoritym Canadian Armed Forces Identificationm Other specify _____________________________________________Document Number:Issuing Jurisdiction:15. Licensed Agentinformation andsignatureThis Application will not beaccepted unless all mandatorysections are completed.By signing below, I confirm that I have:(a) explained and delivered a copy of the Information Folder (including Fund Facts) together with the Annuity Policy and the signedcopy of this application to the Owner;(b) reviewed an original non-expired document to confirm the identity and witnessed the signature(s) of the applicant(s);(c) verified an original valid identification of the Owner/Annuitant and Successor Annuitant (if applicable)to confirm the Owner/Annuitant or Successor Annuitant’s date of birth; and(d) made reasonable efforts to determine if the Owner is acting on behalf of a third party.I also acknowledge that I have disclosed, where applicable, the following items to the Owner of the policy resultingfrom this application:(a) the company or companies I represent;(b) that I will receive compensation (such as commissions or a salary);(c) that I may receive additional compensation in the form of bonuses, conference programs or other incentives; and(d) that I have disclosed any conflicts of interest that I may have with respect to this transaction.Signature of Advisor: ________________________________________Date: DD/MM/YYYYName of Licensed Agent (Last Name, First, Initial(s)) Rep# Dealer number Dealer nameOptional: Phone Number:E-mail address:16. Special InstructionsTransamerica Life Canada • Copy 1: Head Office Copy 2: Advisor Copy 3: Dealer/G.A. Copy 4: Client

Terms and ConditionsWhat you understand and agree to when you sign this Application.Your signature on the application confirms that for all contracts:General• You are applying for a Transamerica Investment Portfolio IIindividual variable insurance contract (“Contract”). Theinformation you have provided in this application is true andcomplete and is the basis for the issuance of this Contract,and you agree to advise us in writing of any changes in theinformation as soon as possible.• The Effective Date of your Contract is the Valuation Datecoinciding with or next following the later of (i) the dateon which we receive your first Deposit; and (ii) the date asshown on the first confirmation notice we send you.• You agree that Transamerica is authorized to acceptinstructions from your advisor to execute financial andcertain non-financial transactions.• If your Contract is held in nominee name, you authorize usto send documents and notices required under the termsof the Contract to your dealer and not to you.• You understand that only certain persons at Transamericaare authorized to make changes to your Contract.For Registered and Locked-in Plans• You are requesting that Transamerica apply for registrationof the Contract applied for as a Retirement Income Fundunder the Income Tax Act (Canada), and, if applicable,under any provincial pension legislation, in accordancewith the Locked-In endorsement attached to the Contract.Personal Information• We collect personal information about you from thisapplication and any supplementary forms, and fromour advisors, agents and representatives and otherorganizations and persons you identify in support ofyour application.• We use your personal information for the purposesof underwriting and investigating the informationprovided in the application, servicing and administeringthis application and/or Contract, investigating andadministering claims, and such other purposes as arespecified in this application.• Your information may be shared with Transamerica’saffiliates and your advisor of record for the purposesidentified above.• Your Social Insurance Number will be used for incomereporting purposes.• Your banking information will be disclosed to the financialinstitution(s) processing your pre-authorized deposit plan.• Upon receiving your application, Transamerica willestablish and maintain a file containing your personalinformation, which will be accessible at Transamerica’sHead Office. Your file will only be accessible to employeesor authorized representatives of Transamerica and otherpersons authorized by you or by law. Subject to exceptionsset out in applicable legislation, you may access your fileand request corrections to your personal information bysending a written request to Transamerica Life Canada,Attn: Privacy Officer, 500 – 5000 Yonge Street, Toronto, ONM2N 7J8.• Your information may be securely used, stored oraccessed in other countries and may be subject to thelaws of those countries. For example, information maybe disclosed in response to demands or requests fromgovernment authorities, courts or law enforcement inthese countries.Systematic Withdrawal PlanIf you have applied for a Systematic Withdrawal Plan (SWP)on this application, you agree as follows:• You authorize Transamerica to make withdrawals from theContract and to credit your bank account in accordancewith your latest written instructions to us.• If you elect direct deposit, you authorize us to credit yourbank account.• If you elect direct deposit, you shall notify us if anychanges are made to your account number, financialinstitution and/ or branch information, in which case wewill require a new void cheque.• We may, at any time, terminate SWP payable byelectronic funds transfer and issue cheques thatrequire personal endorsements.For Quebec Residents who have requested Englishlanguage only.It is my express wish that this application and any relateddocuments be in English. J’ai exigé que la présenteformule et tous les documents s’y rattachant soient rédigésen anglais.Disclosure Statement for The Province of British ColumbiaThe life insurance product you are being offered is supplied by Transamerica Life Canada (“TLC”), a company licensed toconduct business in all provinces and territories of Canada. The advisor/distributor soliciting this insurance application is alicensed life insurance advisor representing TLC and will receive compensation from TLC on the completion of this transaction.You are not obligated to transact any other business with Transamerica Life Canada, the advisor/distributor or any other personor entity as a condition of this application.

imaxxGIF Fund Code ChartimaxxGIF SEGREGATED FUND NAMEMONEY MARKET & FIXED INCOMEMaturity/Death Guarantee Option75% / 75% 75% / 100% 100% / 100%ISC DSC ISC DSC ISC DSCTransamerica Canadian Money Market GIF – imaxxGIF TLC451 TLC450 TLC851 TLC850 TLC251 TLC250Transamerica Canadian Bond GIF – imaxxGIF TLC453 TLC452 TLC853 TLC852 TLC254 TLC255Transamerica TD Income Advantage GIF– imaxxGIF TLC437 TLC436 TLC845 TLC844 N/A N/ATransamerica Canadian Short-Term Bond GIF – imaxxGIF TLC431 TLC430 TLC839 TLC838 TLC253 TLC252CANADIAN BALANCEDTransamerica Canadian Balanced GIF – imaxxGIF TLC461 TLC460 TLC861 TLC860 TLC261 TLC260Transamerica Canadian Fixed Pay GIF – imaxxGIF TLC455 TLC454 TLC855 TLC854 N/A N/ATransamerica Fidelity Canadian Balanced GIF – imaxxGIF TLC433 TLC432 TLC841 TLC840 N/A N/ATransamerica Fidelity Canadian Asset Allocation GIF – imaxxGIF TLC459 TLC458 TLC859 TLC858 N/A N/ATransamerica TD Dividend Balanced GIP – imaxxGIF TLC435 TLC434 TLC843 TLC842 N/A N/ATransamerica TD Dividend Income GIF – imaxxGIF TLC477 TLC476 TLC877 TLC876 N/A N/ACANADIAN EQUITYTransamerica Canadian Equity GIF – imaxxGIF TLC479 TLC478 TLC879 TLC878 N/A N/AASSET allocatION PORTFOLIOSTransamerica CI Conservative GIP – imaxxGIF TLC463 TLC462 TLC863 TLC862 TLC263 TLC262Transamerica CI Balanced GIP – imaxxGIF TLC467 TLC466 TLC867 TLC866 TLC267 TLC266Transamerica CI Growth GIP – imaxxGIF TLC471 TLC470 TLC871 TLC870 TLC271 TLC270Transamerica CI Maximum Growth GIP – imaxxGIF TLC475 TLC474 TLC875 TLC874 N/A N/ATransamerica CI Canadian Balanced GIP – imaxxGIF TLC495 TLC494 TLC895 TLC894 TLC295 TLC294Transamerica Quotential Balanced Income GIF – imaxxGIF TLC441 TLC440 TLC849 TLC848 TLC259 TLC258Transamerica Quotential Balanced Growth GIF – imaxxGIF TLC439 TLC438 TLC847 TLC846 TLC257 TLC256Transamerica Quotential Growth GIF – imaxxGIF TLC443 TLC442 TLC897 TLC896 N/A N/A®Transamerica and the pyramid design are registered trademarks of Transamerica Corporation.Transamerica Life Canada is licensed to use such marks.TMTrademarks of Aegon Canada ULC and/or its affiliates.

500 – 5000 Yonge StreetToronto, Ontario M2N 7J8www.transamerica.caFor more details, please see Transamerica Investment Portfolio II Information Folder/Annuity Policy (IP882/IP882FR).Any amount that is allocated to a segregated fund is invested at the risk of the contract holder(s) and mayincrease or decrease in value.®Aegon and the Aegon logo are registered trademarks of Aegon N.V. Aegon Canada ULC and its affiliated companies are licensedto use such marks.®Transamerica and the pyramid design are registered trademarks of Transamerica Corporation. Transamerica Life Canada is licensed touse such marks.TMTrademarks of Aegon Canada ULC and/or its affiliates.IP881 1/14