APPLICATION FOR CHANGE TO AN EXISTING LIFE INSURANCE

Foresters Life Insurance Company
P.O. Box 41511 Stn Brm B,
1100 - 250 Ferrand Dr,
Toronto, ON, M7Y 7E1
T 416 443 5300
T 1 877 629 9090
F 416 443 6662
Foresters, compagnie d’assurance vie
Case Postale 41511 Stn Brm B,
1100 - 250 Ferrand Dr,
Toronto, ON, M7Y 7E1
Tél 416 443 5300
Tél 1 877 629 9090
Téléc 416 443 6662
www.foresters.com
APPLICATION FOR CHANGE TO AN EXISTING LIFE INSURANCE POLICY
Policy No.
Life Insured name in full
Owner name in full (if other than the life
insured)
A. Changes requested
1.
Addition of
Accidental Death Rider
1 unit
(complete section B)
3 units
5 units (maximum $250,000 coverage)
Child Term Benefit (complete form CPP007)
2.
3.
Decrease life insurance face amount to _
___
Deletion of
Accidental Death Rider
Child Term Benefit
Hospital Cash Benefit
B. Complete for life insured for addition of Accidental Death Rider
Your current occupation: _______________________________________________________________________________
Yes
No
In the past 2 years,
a) except as a fare paying passenger, have you flown in an aircraft as a pilot, crew
member or flight attendant or do you intend to do so in the next 2 years?
b) have you engaged in any hazardous activities such as motorized racing,
underwater diving, aerial activities, or mountain climbing, or do you intend to
do so in the future?
c) have you had your driver’s license suspended or have you had 2 or more
moving violations?
If answered ‘Yes’, please provide details:
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
I, the life insured, declare that the above statements provided are complete and true, and I agree that they shall
form a part of the application to Foresters Life Insurance Company.
Location signed (City & Province)
Date (MM/DD/YYYY)
Signatures
Life insured
Owner (if other than the life insured)
Agent
ForestersTM is the trade name and a trademark of The Independent Order of Foresters and its subsidiary. Foresters Life Insurance Company, is licensed to use this mark.
ForestersTM est le nom commercial et la marque de commerce de L’Ordre Indépendant des Forestiers, et sa société filiale, Foresters, compagnie d’assurance vie, est
autorisée à utiliser cette marque.