PRIOR NOTICE OF REPLACEMENT OF AN INDIVIDUAL DISABILITY INSURANCE CONTRACT
Name of insured: __________________________________
Date of birth of insured: _____/_____/______
Day Month Year
Telephone no.: _________________
REPLACED CONTRACT PROPOSED CONTRACT
Policy no.: ___________________________________________________
Waiting period: ___________________________________________________
Duration of coverage: ___________________________________________________
Amount of benefit: $___________________________$_____________________
Amount of premium: $___________________________$_____________________
REASON FOR REPLACEMENT
(1) How does the current contract fail to meet the client’s needs?
(2) How will the proposed contract better meet the client’s needs?
(3) Will the replacement involve any disadvantages for the client? If so, list them below.
IMPORTANT NOTICE FOR CLIENT
It is of the utmost importance, before signing this form, that you read all the information appearing on the reverse side of the client’s copy.
I hereby acknowledge that I have received a copy of this notice, duly completed, and that a copy of the notice will be sent to the mentioned companies.
Signature (insured): _____________________________________
Name of representative (block letters): _____________________________________
Signature of representative: _____________________________________
(1) White: copy of the policyholder
(2) Yellow: copy of the current insurer
(3) Pink: copy of the new insurer
(4) Gold: copy of the representative
IMPORTANT NOTICE FOR THE INSURED
(1) This notice is intended to inform and protect you as you consider the possibility of amending your disability insurance policy. The change you are considering may require the issue of a new disability insurance policy, or the cancellation of your current policy.
(2) The contract to be replaced should not be terminated before the proposed contract is issued and in force in accordance with your instructions.
(3) The following facts may influence your decision to replace or not to replace your current contract:
(a) the clause providing for the incontestability of the policy after 2 years is not generally transferred from one contract to another. The validity of the new policy may, in some cases, be challenged in a situation where the old contract would have been incontestable.
(b) if your insurability has changed, a new policy may cost more and include more restrictions. You should not amend or cancel your current insurance contract without verifying your insurability.
(c) the new contract may not cover certain health problems which you may have contracted before it was issued and which may be covered by the replaced contract.
Please take these factors into account when you examine the prior notice of replacement.
PROCEDURES TO BE FOLLOWED BY THE REPRESENTATIVE
This document contains information required by the Autorité des marchés financiers when a disability insurance contract is replaced. It must be used whenever a contract is replaced.
(1) Once the form has been duly completed, using a ball-point pen only, and signed by the insured, you must, using registered or certified mail and within 5 days of the signature of the proposal:
(a) send the yellow copy to the head office of the insurer that issued the replaced contract;
(b) send the pink copy to the head office of the insurer issuing the new contract.
(2) The white copy must be given to the insured, and the gold copy must be kept for your records.
(write in capital letters)
Data sheet prepared for: __________________________________ by: _________________________________
Replaced contract Proposed contract
Characteristics of contracts
Amount of benefit $ $
In case of accident
In case of sickness
Rehabilitation coverage yes no yes no
Occupation coverage yes no yes no
Period of occupation coverage
Renewal guarant. not guarant. guarant. not guarant.
Rescindable yes no yes no
Exclusion of pre-existing sickness yes no yes no
Premiums variable level variable level
guarant. not guarant. guarant. not guarant.
At present $ $
In 5 years $ $
In 10 years $ $
Waiver of premiums yes no yes no
Exclusion riders yes no yes no
If yes, list them in If yes, list them in
the comments the comments
section below section below
INTEGRATION OF BENEFIT PROVISION yes no yes no
With government plans
With other contracts yes no yes no
ADJUSTMENT OF BENEFITS yes no yes no
Rate ___ min. ___ max. ___ lev. ___ min. ___ max. ___ lev.
Partial disability yes no yes no
Maximum period of compensation
PARTIAL LOSS OF EARNINGS yes no yes no
Maximum period of compensation
INCREASE OF BENEFIT
Option to increase benefit without
evidence of insurability yes no yes no
Amount $ $
Date of options
Possibility to exercise options
during disability yes no yes no
Accidental death and dismemberment yes no yes no
Amount $ Amount $
COMMENTS: Write in this section any other item comparing or contrasting the replaced contract(s) with the proposed contract.