Schedule BEFORE amended by BC Reg 10/2012, effective January 26, 2012.

Schedule

(Sections 1, 3 and 4)

Basic Disclosure Statement Regarding Replacement

This statement is designed to provide you with information that you might find helpful in deciding whether to change your life insurance. Such a change may involve the use of proceeds available to you under your life insurance to buy replacement life insurance. As it will be necessary to decide what change is the most advantageous for yourself or your beneficiaries, you are encouraged to seek comments or quotations from your life insurance agent and the life insurance company which issued your existing life insurance contract.

In the event that you decide to replace any existing contract(s) of life insurance you should make certain that the new contract(s) that has (have) been delivered to you, is (are) in force and is (are) acceptable to you before you take any action to terminate the existing contract(s).

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The life insurance to be replaced cannot adequately fulfill the policy owner's intended objective for the following reason(s):

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......................................................................[Agent's Name (please print)]

......................................................................[Date]

......................................................................[Agent's Signature]

(a) by replacing my contract of life insurance I may be paying the acquisition costs twice because these are charged in the early years of my contract(s);

(b) because my contract of life insurance was purchased at a younger age, I may pay more for a new contract having the same or similar benefits;

(c) as the incontestable and suicide clauses begin to run again in a new contract, a claim may be denied under a new contract which would have been paid under the contract replaced;

(d) as a change in my health may have adversely affected my insurability, a new contract may contain certain restrictions or limitations and may be more costly;

(e) policy conditions or benefits, including the interest rate on policy loans, may be more favourable under the existing contract of life insurance to be replaced;

(f) if the transaction to purchase a new contract(s) of life insurance involves borrowing the cash value of my existing contract(s) of life insurance beyond my expected ability or intention to repay the loan, a loss or reduction of the benefits under my existing contract(s) of life insurance will result;

(g) by replacing or changing my contract of life insurance acquired prior to December 2, 1982, or in the case of corporate owned life insurance prior to June 29, 1982, I may lose valuable tax advantages within the existing policy.

A copy of this disclosure form will be sent to the life insurers which issued the contract(s) of life insurance to be replaced.

I also acknowledge receipt of a fully completed Disclosure Statement Regarding Replacement of Contracts of Life Insurance and acknowledge that it was presented to me before the application for new insurance was signed.

I have been advised by the agent who signed this form that I may withdraw, in writing, my application for new insurance within 20 days and that the insurer will refund any premium deposit or other payment made by me in respect of the proposed replacement of a contract of life insurance, except if the application is for a single premium life insurance policy, or a policy the value of which depends upon a stated rate of interest and/or a stated group of assets, in which case the refund shall be adjusted to reflect the change in the capital value of the contract.

...................[Date] ..................................................[Signature of Applicant]

..................................................[Name of Applicant (please print)]

...................[Date] ..................................................[Signature of Applicant]

..................................................[Name of Life Insured (if other than applicant) (please print)]

NOTE TO AGENT: If more than one existing contract of life insurance is to be replaced, a separate form must be completed for each existing contract.

This form has been approved by C.L.H.I.A. and L.U.A.C. and is recommended for use by the Canadian Council of Insurance Regulators

Basic Disclosure Statement Regarding Replacement of
Contracts of Life Insurance

			Existing Insurance	Proposed Insurance
GENERAL INFORMATION
Policy Number
Name of life insured
Date of birth of life insured
Name of policy owner (if other than life insured)
Insurance company
Type of contract (Whole Life, Term, Univ. Life, etc.)
Date of Application
Note: The date your existing life insurance   policy was acquired will be a major   factor in determining the tax rules that   will apply of the policy is surrendered   or changed.
Date of issue
Issued standard			Yes No
Policy registered			Yes No	Yes No
Guaranteed insurability option (at what ages)
Loan interest rate
Loan outstanding			Yes No
Date suicide period expires
Date contestable period expires
Additional benefits (specify)
DEATH BENEFITS
Face amount of  insurance	-	now
	-	at age 65
	-	protection expires
Face Amount of Term Rider	-	now
	-	at age 65
	-	protection expires
Additional Death Benefit (specify)
GUARANTEED CASH VALUES OR DEPOSITS
Now
At age 65
Current and projected interest rate if applicable
(Adjustable contract, eg. Univ. Life)
DIVIDENDS
Participating Policy			Yes No	Yes No
Dividend option selected
ANNUALIZED PREMIUMS
Basic Policy	-	current amount
	-	guaranteed until
	-	payable until
Term Rider	-	current amount
	-	guaranteed until
	-	payable until
Additional Benefits	-	current amount
	-	guaranteed until
	-	payable until
Total annualized premium
Have the income tax implications of this change or replacement been fully explained to the policyowner			Yes No
Additional comments/special circumstances
Agent's Name (please print)			Applicant's Name (please print)
Agent's Signature			Applicant's Signature
Date