ADVISOR DISCLOSURE

Licensing

I______am licensed as a life (and health) insuranceagent/financial security advisorin the province(s) of ______(In Quebec provide list by license class). I am also licensed/registered in the following fields and jurisdictions: ______

For insurance products, I place business through ______(name of distribution firm(s). For other products, I place business through ______(name of distribution firm(s).

Companies I Represent

I currently hold contracts with the following insurance companies and financial service providers:

______

______

Relationship with the Companies I Represent

No insurance company or other financial services entity holds an ownership interest in my business, nor do I hold an interest in anyinsurance company or other financial services entity.

Compensation

I am compensated by a sales commission on policies I sell. I may receive a renewal (or service) commission on policies that remain active. Commissions are paid by the company that provides the product you purchased. I may also receive compensation from the MGA/distribution firm through which I place my business. I may be eligible for additional compensation, such as bonuses and other benefits, such as conferences, based on my sales volume.

Quebec: In addition to the above disclosures, you must disclose if you will also be compensated by the policy owner.

Disclose here any:

-fees charged

-referral arrangements

-split commission arrangements

-other businesses engaged in

Conflict of Interest(select one option)

I confirm that I have no conflict of interest. If I become aware of a potential or real conflict, I will inform you.

My position/profession as ______may be perceived to be a potential conflict of interest with respect to my recommendations to you. However, I confirm my overall recommendations will be based on my analysis of your needs.

For other types of conflicts:

The following situation may be perceived to be a conflict of interest. However, I confirm that my recommendations will be based on my assessment of your needs.

______

More information

Should you require additional information about my qualifications or the nature of my businessrelationships,please contact me. I would be pleased to answer your questions.

Acknowledgement and Consent:

Ihave been informed of, and understand the implications of, this disclosure,including any conflict of interest or potential conflict of interest associated with the Advisor inrelation to any recommendations made.

I______am responsible for the accuracy of the information on this form.
Advisor Name

Privacy Policy and Policy Owner Statement

I try to maintain the highest standards of confidentiality in dealing with client information and I adhere to the Personal Information Protection and Electronic Documents Act (“PIPEDA”), a federal privacy law and any provincial privacy laws and regulations that apply.

  1. Accountability – I am accountable for the personal information I receive from my clients and I will abide by the principles of PIPEDA in safeguarding that information in hard copy and computer documents. (Any employees I have also understand and abide by these rules).
  1. Collection Purposes, Limitations on Collection, Use, Disclosure and Retention – Any and all personal (including medical), corporate, financial and related information is collected, used and retained for the purposes of establishing a file, providing ongoing advice and service and meeting insurers’ need for specific information in connection with your application for insurance. I confidentially convey your personal information to insurers though wholesale organizations, including Managing General Agencies. I only collect and keep information that helps me formulate advice including personal, financial and health information. With your consent, I may share this information with my associates to get you help in areas outside of my expertise.
  1. Consent – The nature of my work means I must receive and retain a lot of personal information about my clients including health data, financial data and identity verification. I use this information to make judgments about your situation and to identify possible solutions to any problems you might have. In becoming my client, and by signing this form, you agree to give me this information, allow me to share this information with my suppliers and wholesale organizations and allow me to retain it in my paper and electronic files for as long as you wish me to be your advisor or I have a business need to retain the information. You may withdraw your consent at any time but that will end our business relationship.
  1. Information Accuracy – I rely on receiving accurate information in order to make appropriate recommendations. You may review the personal information I retain about you upon request. I will also update the information regularly in an effort to ensure I am making recommendations about your situation based on the correct information.
  1. Safeguards – All the written information I receive from you is either in secure filing cabinets or in password protected computer files. Any computer files stored off site are encrypted or locked. Old files that are discarded are shredded or otherwise completely destroyed. My staff understands the sensitivity of this information and the importance of protecting it.
  1. Questions, Concerns and Access – You may contact me at anytime by telephone, email or letter at the address shown on this page about your files with me and request changes. You may review PIPEDA online at If you have any complaints about my procedures I will investigate and provide you with a response as soon as practical. A full copy of my Privacy Policy is available upon request.
  1. Communicating Electronically

In the normal course of business, I may communicate with you through electronic means such as email. By checking the appropriate box and signing below, you give me your consent to do so. You may revoke your consent at any time.

Consents

I consent to the collection, use, retention and sharing of my personal information, including health information provided to insurers and copies of my application.

□I consent to the Advisor communicating electronically with me in the course of business.

______

Signature of ProposedInsured / Annuitant Date Signature of Policy Owner(s) (if other than Insured) Date

______

Signature of Advisor(s)Date

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