QUICK ISSUE CRITICAL ILLNESS

PRODUCT GUIDE

®

QUICK ISSUE CI Our Quick Issue Critical Illness Insurance At-A-Glance

Face Amount $10,000 - $100,000

Issue Ages 18 - 60

Premiums Level, Guaranteed

Illnesses Covered 14 Illnesses:Heart Attack, Stroke, Cancer (Life-Threatening), Coronary Artery Bypass Surgery, Failure of Both Kidneys, Major Organ Transplant, Major Organ Failure on Waiting List, Paralysis, Occupational HIV Infection, Blindness, Deafness, Loss of Speech, Loss of Limbs, and Severe Burns.

Return of Premium (ROP) Features

Return of Premium on Death (included in all plans)Flexible Return of Premium (included in T75 ROP plan only)

Simplified Underwriting 8 Qualifying Questions + Medical Information Bureau Inc. (MIB, Inc.)

Premium Payment Methods

Annual (Pre-Authorized Debit (PAD) or billing)Semi-Annual (PAD or billing)Monthly (PAD)

Plan Types Term 10 to Age 75Term to Age 75Term to Age 75 with Flexible Return of Premium (ROP)

Coverage To age 75

Policy Fee $60

The Quick Issue Critical Illness plan provides a lump sum living benefit to the owner of the plan on the occurrence of the first of one of the following specific critical illnesses of the insured provided the insured survives the waiting period following the onset of the critical illness. The waiting period is 30 days from diagnosis unless a longer period is specified in the Definitions of Insured Conditions as outlined in this guide. No living benefit is payable if cancer is diagnosed within 90 days of issue. If death occurs prior to, or within 30 days of, onset of the specified critical illness, a return of basic premium will be paid to the beneficiary.

The Quick Issue Critical Illness plan has three premium payment options:

10 Year Term Renewable to Age 75 provides a level amount of critical illness insurance which can be renewed every 10 years until age 75 of the insured at which time the insurance terminates. Premiums increase at each renewal.

Level Term to Age 75 provides a level amount of critical illness insurance until age 75 of the insured at which time the insurance terminates. Premiums are level and guaranteed at issue.

Level Term to Age 75 with Flexible ROP provides a level amount of critical illness insurance until age 75 of the insured at which time the insurance terminates. Premiums are level and guaranteed at issue. If the insured reaches the later of age 65 or 10 policy years before a critical illness benefit is paid and the policy is in force, the Company will refund to the policy owner 50 percent of annual premiums paid on the in force volume at the time of surrender, proportionately increasing to 100 percent return of premium at age 75.

The Quick Issue Critical Illness plan is issued upon answering ‘No’ to just 8 qualifying questions, provided there are no unfavourable reports from the Medical Information Bureau.

The 14 Covered Illnesses include: Heart Attack, Stroke (Cerebrovascular Accident), Cancer (Life-Threatening), Coronary Artery Bypass Surgery, Failure of Both Kidneys, Major Organ Transplant, Major Organ Failure on Waiting List, Paralysis, Occupational HIV Infection, Blindness, Deafness, Loss of Speech, Loss of Limbs, and Severe Burns.

QUICK ISSUE CI What is Wawanesa Life’s Quick Issue Critical Illness plan?

QUICK ISSUE CI Qualifying Questions

Within the last two years, have you had an application for individual life insurance or critical illness insurance rated, declined, postponed or had exclusions added by Wawanesa Life or any other company?

Have you ever been treated for, diagnosed, consulted a doctor, received abnormal test results or experienced symptoms of the following:

a) Heart attack, congenital cardiac defects, angina, angioplasty, coronary artery bypass, congestive heart failure, stroke, transient ischemic attack (TIA), arteriosclerosis or any other cerebrovascular disease or disease of the heart or the blood vessels, or an abnormal electrocardiogram (EKG)?

b) Type 1 (insulin-dependent) diabetes or type 2 diabetes?

c) Cancer or other malignant disease, growth, tumour or colon polyp?

d) Multiple sclerosis or motor neuron disease?

e) Any breast disorders (mass, cyst, unusual discharge, physical change, abnormal mammogram or biopsy) or prostate disorders (nodule or abnormal PSA)?

f) Any eye or ear problems or diseases other than corrected by glasses, contact lenses or hearing aids?

a) Have you consulted a physician for an illness or condition which has not yet been diagnosed or for which testing is still in progress?

b) Have you noticed any symptoms or health problems for which you have not yet consulted a physician, such as: lump or mass of the breasts, shortness of breath, chest pain, dizziness, loss of balance, numbness, rectal bleeding, prostate or other problems?

Have you ever tested positive for HIV or been diagnosed, treated for or had any indication of AIDS, AIDS related complex, liver or kidney failure, cirrhosis, chronic kidney disease, hepatitis B or C, or carrier of hepatitis B?

Within the last five years, have you received treatment or been advised to seek treatment or medical advice because of your alcohol usage?

Within the last five years, have you used: heroin, cocaine, hallucinogens or any other hard drugs other than as prescribed by a doctor, or methadone whether prescribed by a doctor or not, or have you received treatment or been advised to seek treatment or medical advice because of your drug usage?

To the best of your knowledge, has one of your natural parents or siblings ever suffered from, or are suffering from heart disease, cancer, stroke or transient ischemic attack (TIA) prior to the age of 55?

Does your current weight exceed the weight indicated in the maximum weight table to the right?

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Preliminary question on application: Are you a Canadian citizen or landed immigrant, currently residing in Canada? (If No, coverage is not available)

Heart Attack shall mean a definite Diagnosis of the death of heart muscle due to obstruction of blood flow, resulting in the rise and fall of biochemical cardiac markers to levels considered diagnostic of myocardial infarction, with at least one of the following:

1. heart attack symptoms;

2. new electrocardiogram (EKG) changes consistent with a heart attack; or

3. development of new Q waves during or immediately following an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty.

The Diagnosis of Heart Attack must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for:

• elevated biochemical cardiac markers as a result of an intra-arterial cardiac procedure including, but not limited to, coronary angiography and coronary angioplasty, in the absence of new Q waves, or

• EKG changes suggesting a prior myocardial infarction, which do not meet the Heart Attack definition as described above.

Stroke is defined as a definite Diagnosis of an acute cerebrovascular event caused by intra-cranial thrombosis or hemorrhage, or embolism from an extra-cranial source, with acute onset of new neurological symptoms, and new objective neurological deficits on clinical examination, persisting for more than 30 days following the date of Diagnosis.

These new symptoms and deficits must be corroborated by diagnostic imaging testing. The Diagnosis of Stroke must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for:

• Transient Ischaemic Attacks; or

• Intracerebral vascular events due to trauma; or

• Lacunar infarcts which do not meet the definition of stroke as described above.

HEART ATTACK

STROKECerebrovascular

Accident

DEFINITIONS of Insured Conditions

Cancer shall mean a definite Diagnosis of a tumour characterized by the uncontrolled growth and spread of malignant cells and the invasion of tissue. The Diagnosis of Cancer must be made by a Specialist.

Exclusion: No benefit will be payable under this condition for the following non-life-threatening cancers:

1. carcinoma in situ, or

2. Stage 1A malignant melanoma (melanoma less than or equal to 1.0 mm in thickness, not ulcerated and without Clark level IV or level V invasion), or

3. any non-melanoma skin cancer that has not metastasized, or

4. Stage A (T1a or T1b) prostate cancer.

Cancer Exclusion and Policy Termination

There shall be no coverage under the Insured Condition definition of Cancer, if any signs, symptoms or investigations that lead to a Diagnosis of cancer (covered or excluded under the policy), regardless of when the Diagnosis is made, commenced within the 90 days following the later of the Issue Date and the date of last Reinstatement of the policy. In the event of any Diagnosis based on such a sign, symptom or medical problem, the policy is terminated, and the Company’s sole liability in respect of the policy shall be limited to a refund, to the Policy Owner, of the premiums due and paid since the later of the Issue Date and the date of the last Reinstatement of the policy.

This medical information as described above must be reported to the Company within 6 months of the date of the Diagnosis. If this information is not provided, the Company has the right to deny any claim for cancer or, any critical illness caused by any cancer or its treatment.

Coronary Artery Bypass Surgery shall mean the undergoing of heart Surgery to correct narrowing or blockage of one or more coronary arteries with bypass graft(s), excluding any non-surgical or trans-catheter techniques such as balloon angioplasty or laser relief of an obstruction. The Surgery must be determined to be medically necessary by a Specialist.

Failure of Both Kidneys shall mean a definite Diagnosis of chronic irreversible failure of both kidneys to function, as a result of which regular haemodialysis, peritoneal dialysis or renal transplantation is initiated. The Diagnosis of Failure of Both Kidneys must be made by a Specialist.

CANCERLife Threatening

CORONARY ARTERY BYPASS

SURGERY

FAILURE OFBOTH KIDNEYS

Major Organ Transplant shall mean a definite Diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under Major Organ Transplant, the Insured must undergo a transplantation procedure as the recipient of a heart, lung, liver, kidney or bone marrow, and limited to these entities. The Diagnosis of the major organ failure must be made by a Specialist.

Major Organ Failure on Waiting List shall mean a definite Diagnosis of the irreversible failure of the heart, both lungs, liver, both kidneys or bone marrow, and transplantation must be medically necessary. To qualify under Major Organ Failure on Waiting List, the Insured must become enrolled as the recipient in a recognized transplant centre in Canada or the United States of America that performs the required form of transplant Surgery. For the purposes of the Survival Period, the date of Diagnosis is the date of the Insured’s enrolment in the transplant centre. The Diagnosis of the major organ failure must be made by a Specialist. The Insured must survive at least 30 days following the date of enrollment into the transplant program.

Paralysis shall mean a definite Diagnosis of the total irreversible loss of muscle function of two or more limbs as a result of injury or disease to the nerve supply of those limbs, for a continuous period of at least 90 days following the precipitating event. The Diagnosis of Paralysis must be made by a Specialist.

Occupational HIV Infection shall mean a definite Diagnosis of infection with the Human Immunodeficiency Virus (HIV) resulting from an accidental injury during the course of the Insured’s normal occupation, which exposed the Insured to HIV contaminated body fluids.

The accidental injury leading to the infection must have occurred after the later of the Issue Date of the policy or the effective date of last Reinstatement of the policy.

Payment under this condition requires satisfaction of ALL of the following:

1. The accidental injury must be reported to the Company within 14 days of the accidental injury;

2. A serum HIV test must be taken within 14 days of the accidental injury and the result must be negative,

3. A serum HIV test must be taken between 90 days and 180 days after the accidental injury and the result must be positive;

4. All HIV tests must be performed by a duly licensed laboratory in Canada, the United States of America or in any other jurisdiction as approved by the Company;

5. The accidental injury must have been reported, investigated and documented in accordance with current Canadian or United States of America workplace guidelines.

MAJOR ORGANFAILURE ON

WAITING LIST

PARALYSIS

OCCUPATIONALHIV INFECTION

MAJOR ORGANTRANSPLANT

The Diagnosis of Occupational HIV Infection must be made by a Specialist

No payment will be payable under this condition if:

1. The Insured has elected not to take any available licensed vaccine offering protection against the HIV, or

2. A licensed cure for HIV infection has become available prior to the accidental injury, or

3. HIV infection has occurred as a result of non-accidental injury including, but not limited to, sexual transmission and intravenous (IV) drug use.

Blindness shall mean a definite Diagnosis of the total and irreversible loss of vision in both eyes. The corrected visual acuity must be 20/200 or less in both eyes or the field of vision must be less than 20 degrees in both eyes. The Diagnosis of Blindness must be made by a Specialist.

Deafness shall mean a definite Diagnosis of the total and irreversible loss of hearing in both ears, with an auditory threshold of 90 decibels or greater within the speech threshold of 500 to 3,000 hertz. The Diagnosis of Deafness must be made by a Specialist.

Loss of Speech shall mean a definite Diagnosis of the total and irreversible loss of the ability to speak for a continuous period of at least 180 days due to physical injury or physical disease. The Diagnosis of Loss of Speech must be made by a Specialist. No benefit will be payable under this condition for any psychiatric related causes.

Loss of Limbs shall mean a definite Diagnosis of the complete severance of two or more limbs at or above the wrist or ankle joint as a result of an accident or medically required amputation. The Diagnosis of Loss of Limbs must be made by a Specialist.

Severe Burns shall mean a definite Diagnosis of third-degree burns covering at least 20% of the body surface. The Diagnosis of Severe Burns must be made by a Specialist.

OCCUPATIONALHIV INFECTION

(continued)

BLINDNESS

DEAFNESS

LOSS OF SPEECH

LOSS OFLIMBS

SEVERE BURNS

BENEFITS & CONDITIONS

Critical Illness Benefit The Critical Illness Benefit shall be payable to the Policy Owner on the first completion of a Waiting Period while this policy is in force for one of the Critical Illness Insured Conditions, subject to the other provisions of the policy. The Critical Illness Benefit amount is the then current Sum Insured, as shown in the policy face page or in the latest amendment to the contract agreed upon in writing. The Critical Illness Benefit is only payable once, and the policy then terminates, regardless of the number of Critical Illnesses that may be diagnosed. Payment of the Critical Illness Benefit will represent full and final discharge of all claims under the policy respecting the Insured.

Return of Premium on Death Benefit

The Return of Premium on Death Benefit shall be payable if the Insured does not survive the Waiting Period, or if the Insured’s death results from any cause other than a Critical Illness Insured Condition, subject to the other provisions of the policy. The Return of Premium on Death Benefit amount is the sum of the annual premiums due for the policy that were paid prior to the Insured’s death, adjusted for any partial surrenders (the total payout would be calculated assuming the reduced Critical Illness benefit had been in force from the Issue Date of the policy), and will be payable in accordance with the beneficiary designation then in effect. Due proof of the Insured’s death and proof of claim, which are satisfactory to the Company, must be submitted to the Company’s Executive Office. No Return of Premium on Death Benefit is payable if the Critical Illness Benefit is payable. The Return of Premium on Death Benefit is only payable once, and the policy then terminates. Payment of the Return of Premium on Death Benefit will represent full and final discharge of all claims under the policy respecting the Insured.

Flexible Return of Premium Benefit

The Flexible Return of Premium Benefit shall be payable on surrender at the later of age 65 or 10 years from the Issue Date, or at the Expiry Date if the policy is in force and the Insured is alive at that time. No Flexible Return of Premium Benefit is payable if the Critical Illness Benefit is payable. When the Flexible Return of Premium benefit has been paid, the coverage terminates.

The Flexible Return of Premium Benefit amount is equal to a percentage of annual premiums paid, without interest, depending on the attained age and number of years the policy has been in force, according to the values shown in the Flexible Return of Premium Benefit Table included in the policy.

Any reduction in the Critical Illness Benefit will be treated as a lapse of coverage and any future Flexible Return of Premium Benefit will be calculated assuming the reduced Critical Illness Benefit had been in force from the Issue Date of the policy.

SAMPLE Contract Provisions

ExclusionsNo Critical Illness Benefit shall be due or payable if the Insured Condition results, directly or indirectly, from any one or more of the following causes:

1. the Insured attempts to take his/her own life, or inflicts injuries on his/her own person, whether or not in possession of his/her mental faculties;

2. any violation by the Insured of the criminal law;

3. the Insured’s use of illegal or illicit drugs or substances, or the Insured’s misuse of medication obtained with or without prescription, or the Insured’s misuse of alcohol;

4. war, whether such war is declared or undeclared, or hostile action of the armed forces of any country, or insurrection or civil commotion, irrespective of whether the Insured were actually a participant or not;

5. any sign, symptom or medical problem of the Insured, which initiated any investigation leading to the Diagnosis of a Critical Illness (other than Cancer), and which commenced prior to the later of the Issue Date and the date of the last Reinstatement of the policy.

ClaimsAny claim for payment of benefit must be submitted in writing to the Company’s Executive Office. The Company will furnish forms for proof of claim within 15 days after receiving notice of claim. Before the Company makes any settlement under this policy, the claimant must provide evidence, satisfactory to the Company, of the occurrence of the claim. The Company shall have the right to require examination of the Insured, and confirmation of the Diagnosis of any Critical Illness Insured Condition, by any Doctor appointed by the Company. The Company is also entitled to receive proof of the Insured’s date of birth and, if applicable for the claim, proof of the Insured’s death.

Any Critical Illness Benefit amount due during the Insured’s lifetime is payable to the Policy Owner, if living, otherwise to the Policy Owner’s estate.

Extension of BenefitIf the Final Expiry Date of the policy occurs during a Waiting Period immediately following the date of the Insured’s Diagnosis or Surgery, the policy shall continue in force until the earlier of the Insured’s death and the end of the Waiting Period.

PREMIUMS

Payment of PremiumsThe Issue Date and the Premium Period are shown in the policy face page. The first premium is payable on the Issue Date. If the Company consents, the premium payment frequency can be changed to other than annually. The amount of the premium on a frequency other than annually will be determined by the Company. Each premium after the first is payable in advance on the first day of each premium frequency as measured from the Issue Date. Premiums are payable during the Insured’s lifetime until the earlier of the Final Expiry Date and the date a Critical Illness Benefit becomes payable. Premiums are payable at the Company’s Executive Office, or elsewhere in accordance with the Company’s then current rules.

If any cheque, or other such instrument used to pay premiums is not paid when presented for payment by the Company in the normal course of business, the premium will be considered unpaid.

Grace PeriodA grace period of 30 days is allowed for payment in full of any premium due, except the first. The policy remains in force during the Grace Period. If a premium due is not paid by the end of the Grace Period, the policy will then lapse.

ReinstatementIf this policy has lapsed, an application to reinstate it can be made within 1 year after the first unpaid premium was due.

To reinstate this policy, the Company requires proof, satisfactory to the Company, that the Insured is insurable, together with the payment of all overdue premiums, and interest at an appropriate rate then set by the Company.

The reinstated policy will come into force on the earliest date on which the Company has approved the application for reinstatement and the preceding terms of this provision have been satisfied.

GENERAL PROVISIONS

Policy OwnerThe first Policy Owner of this policy is the person who makes the contract with the Company, and is named in the application. The Policy Owner has the rights and privileges granted by this policy, including but not limited to the right to receive any payments due during the Insured’s lifetime. If the policy is assigned, these rights will be subject to the terms of that assignment.

BeneficiaryThe first beneficiary or beneficiaries, for any amounts due as a result of the Insured’s death, will be as stated in the application. During the Insured’s lifetime the Policy Owner may designate in writing to the Company one or more beneficiaries to receive any such amounts, and may revoke or change a designation as permitted by law.

The Company will pay any amounts due as a result of the Insured’s death under the beneficiary designation in effect at the date of the Insured’s death. If more than one beneficiary has been designated and one or more of them dies, such amounts will be paid to the beneficiary surviving at the date of the Insured’s death or, if there is more than one, to each of them equally. If no beneficiary is living when the Insured dies and no other designation is then in effect, any such amounts will be paid to the Policy Owner or the Policy Owner’s estate.

AssignmentThe Policy Owner can assign this policy as permitted by law. An assignment of this policy or of an interest in it will not be binding on the Company until the assignment or a certified copy of it is filed with the Company’s Executive Office. The Company is not responsible for the validity or effect of any assignment.

IncontestabilityThe Insured, and the Policy Owner if other than the Insured, is required to disclose to the Company in any applications, on any medical examination and in any written statements or answers furnished as evidence of insurability for this policy, every fact that is material to the insurance and is known to either of the Insured or the Policy Owner. A failure to disclose, or a misrepresentation of such a fact, will render the contract voidable by the Company.

However, the Company will not contest this policy after it has been in force continuously, during the Insured’s lifetime, for 2 years from the later of the Issue Date and the date of the last Reinstatement of the policy, except in the case of fraud, or a claim for a Critical Illness Insured Condition of the Insured where the Insured’s symptoms or medical problems which initiated any investigation leading to the Diagnosis commenced before the end of this 2 year period.

The Company reserves the right to contest any amendment to the contract which increases the insurance money payable or improves the Policy Class, but not after the amendment has been in force continuously, during the Insured’s lifetime, for 2 years from the later of the date the amendment first takes effect and the date of the last Reinstatement of the policy, except in the case of fraud, or a claim for a Critical Illness Insured Condition of the Insured where the Insured’s symptoms or medical problems which initiated any investigation leading to the Diagnosis commenced before the end of this 2 year period.

This provision does not apply to any misstatement of the Insured’s age or sex.

Misstatement of Age & SexIf the Insured’s date of birth or sex has been misstated, any amounts payable will be the amounts which the premiums paid would have bought for the correct date of birth and sex. However, where the Insured’s Age affects the commencement or termination of any insurance under this policy, the Insured’s true Age governs.

ConsiderationThis policy is issued on the basis of the statements in the application, and in return for payment, on or before delivery of the policy, of the premium for the initial premium period.

Currency & Place of PaymentAll amounts payable to or by the Company under this policy are payable in Canada in Canadian currency.

Non ParticipatingThis policy is not eligible for dividends and will not participate in our divisible surplus.

The ContractThe contract consists of this policy, the application for insurance and any amendment agreed upon in writing. Any change in this contract may be made only with the written consent of the Policy Owner and the Company. If the Life Insured reasonably fears for their life or health, they can apply to court to have the policy terminated. Only the President, the Vice President, the Secretary or the Actuary of the Company have authority to waive or agree to change any of the conditions or provisions of this policy. The Company may charge a reasonable fee for a second copy of policy and/or application.

WaiverThe Company will be deemed not to have waived any condition of this contract, either in whole or in part, unless the waiver is clearly expressed in writing signed by the Company.

Copy of ApplicationThe Company will upon request, furnish to the Policy Owner or to a claimant under the contract a copy of the application.

Notice and Proof of ClaimThe Insured or the Policy Owner, or a beneficiary entitled to make a claim, or the broker of any of them, must

1. give written notice of claim to us, within 30 days from the date a claim arises under the contract,

a) by delivery of the notice of claim or by sending it by registered mail, to the Company’s Executive Office or an agency office of the Company in the province, or

b) by delivery of the notice of claim to one of the Company’s authorized brokers in the province,

2. within 90 days from the date a claim arises under the contract, furnish to the Company such proof of claim as is reasonably possible in the circumstances of the happening of the claim, the right of the claimant to receive payment, and his or her age, and the age of the beneficiary, if relevant; and

3. if so required by the Company, furnish a satisfactory certificate as to the cause or nature of the injury, sickness, or disability for which the claim may be made under the contract and, if applicable, the duration of such disability.

Failure to give Notice or ProofFailure to give notice of claim or furnish proof of claim within the time prescribed by the statutory provision above does not invalidate the claim if the notice or proof is given or furnished as soon as reasonably possible, and in no event later than 1 year from the date of the injury or the date a claim arises under the contract, if it is shown that it was not reasonably possible to give notice or furnish proof within the time so prescribed.

Company to furnish forms for Proof of ClaimThe Company will furnish forms for proof of claim within 15 days after receiving notice of claim, but where the claimant has not received the forms within that time, he or she may submit his or her proof of claim in the form of a written statement of the cause or nature of the injury, sickness or disability giving rise to the claim.

Rights of ExaminationAs a condition precedent to recovery of insurance money under this contract, the Insured will be required to allow the Company an opportunity to examine the Insured when and so often as the Company reasonably requires while the claim under this policy is pending.

When Money PayableAll money payable under this contract will be paid by the Company within sixty days after the Company has received proof of claim.

Limitation of ActionsAn action or proceeding against the Company for the recovery of a claim under this contract may not be commenced more than 1 year after the date the insurance money became payable or would have become payable if it had been a valid claim.

Notice of Consent & Disclosure Regarding Personal InformationThe Company collects, uses and discloses personal information in order to administer the products and services the Policy Owner has requested. Personal information is collected, used and disclosed for the purposes of: establishing and maintaining communications with the Policy Owner; underwriting risks on a prudent basis; investigating and paying claims; receiving payments of insurance premiums and policy loan repayments; withdrawing premiums from and depositing funds into Payer’s account (applicable if PAD Agreement is signed); detecting and preventing fraud; offering and providing products and services to meet the Policy Owner’s or the Life Insured’s needs; compiling statistics; and acting as required or authorized by law.

We may share the Policy Owner’s or Life Insured’s personal information with the following people, organizations and service providers: the Company’s employees and brokers who require this information to perform their jobs; third party providers who require this information to provide their services, which may include paramedical agencies, underwriters, claims investigators, investigative agencies, providers of information processing and storage, programming, printing, mailing and distribution services; applicable reinsurance companies to allow them to evaluate and administer any insurance risk that they accept; the Medical Information Bureau as explained in the notice provided; people to whom the Policy Owner has granted access; and people who are legally authorized to view the Policy Owner’s or Life Insured’s personal information. These people, organizations and service providers may be in other provinces or jurisdictions outside Canada. The information may be shared as required by the laws of those jurisdictions.

In order to provide services to the Policy Owner or the Life Insured in the future and provide the benefits included in the policy, the Company may need to collect, use and disclose additional personal information about the Policy Owner or the Life Insured. The Company may not require the Policy Owner or the Life Insured to provide consent at that time.

Any restriction or withdrawal of the consent may result in the Company being unable to provide the product or service being applied for or having to terminate the policy.

Further information about the Company’s Personal Information Protection Policy can be obtained from the Company’s Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at www.wawanesalife.com.

Policy fee is $60 per year | Volumes available from $10,000 - $100,000 | Issue Ages: 18 - 60 for all plans Multiply the annual premium by 0.09 to obtain the monthly premium or by 0.52 for semi-annual premium. Smoker rates apply if, within the last 12 months, you have used any tobacco or nicotine products including cigarettes, cigarillos, colts, cigars, pipes, chewing tobacco, snuff, e-cigarettes, nicotine gum or patches or any form of nicotine substitute.

RATE TABLE per $1,000 of coverageAge

Nearest Birthday

TERM 10 to AGE 75 TERM to AGE 75 TERM to AGE 75 ROPMALE FEMALE MALE FEMALE MALE FEMALE

Non-Smoker Smoker Non-Smoker Smoker Non-Smoker Smoker Non-Smoker Smoker Non-Smoker Smoker Non-Smoker Smoker

18 2.13 2.52 2.13 2.15 4.05 6.55 3.60 6.10 5.35 7.60 5.09 7.1719 2.14 2.56 2.14 2.25 4.15 6.70 3.75 6.25 5.50 7.80 5.24 7.4220 2.15 2.60 2.15 2.35 4.25 6.85 3.90 6.40 5.65 8.00 5.39 7.6721 2.18 2.68 2.17 2.52 4.44 7.12 4.11 6.64 5.87 8.39 5.62 8.1222 2.20 2.75 2.19 2.69 4.64 7.40 4.34 6.89 6.10 8.81 5.87 8.6023 2.23 2.83 2.21 2.88 4.85 7.69 4.58 7.15 6.34 9.24 6.13 9.1024 2.25 2.92 2.23 3.08 5.07 7.99 4.83 7.42 6.59 9.69 6.39 9.6325 2.28 3.00 2.25 3.30 5.30 8.30 5.10 7.70 6.85 10.17 6.67 10.2026 2.38 3.21 2.37 3.56 5.60 8.81 5.30 8.19 7.24 10.86 6.96 10.8527 2.49 3.43 2.49 3.83 5.92 9.36 5.51 8.72 7.65 11.59 7.27 11.5528 2.61 3.67 2.62 4.13 6.26 9.93 5.73 9.27 8.09 12.37 7.58 12.2929 2.73 3.93 2.76 4.45 6.62 10.55 5.96 9.87 8.54 13.21 7.91 13.0830 2.85 4.20 2.90 4.80 7.00 11.20 6.20 10.50 9.03 14.10 8.26 13.9231 2.97 4.51 3.03 5.15 7.28 12.03 6.49 11.25 9.52 15.12 8.77 14.8232 3.09 4.84 3.16 5.52 7.57 12.92 6.80 12.05 10.03 16.22 9.32 15.7833 3.22 5.20 3.30 5.92 7.86 13.87 7.12 12.90 10.57 17.40 9.89 16.8034 3.36 5.59 3.44 6.34 8.18 14.90 7.45 13.82 11.14 18.66 10.51 17.8835 3.50 6.00 3.59 6.80 8.50 16.00 7.80 14.80 11.74 20.01 11.16 19.0436 3.76 6.63 3.83 7.51 8.95 17.20 8.16 15.72 12.48 21.25 11.94 19.9937 4.04 7.32 4.10 8.30 9.42 18.50 8.55 16.69 13.26 22.56 12.77 20.9838 4.34 8.08 4.37 9.17 9.92 19.89 8.94 17.73 14.09 23.95 13.65 22.0239 4.66 8.92 4.67 10.14 10.45 21.39 9.36 18.83 14.98 25.43 14.60 23.1240 5.00 9.85 4.99 11.20 11.00 23.00 9.80 20.00 15.92 27.00 15.62 24.2741 5.47 10.98 5.43 12.07 11.46 24.57 10.24 20.91 17.13 29.63 16.63 26.1442 5.97 12.24 5.90 13.01 11.94 26.25 10.70 21.87 18.43 32.52 17.71 28.1643 6.53 13.64 6.42 14.03 12.44 28.04 11.18 22.87 19.83 35.70 18.86 30.3444 7.14 15.20 6.99 15.12 12.96 29.95 11.68 23.91 21.34 39.18 20.08 32.6845 7.80 16.94 7.60 16.30 13.50 32.00 12.20 25.00 22.96 43.00 21.38 35.2046 8.32 18.73 8.06 17.61 14.44 34.26 12.71 26.43 24.71 46.56 22.47 37.6847 8.87 20.71 8.55 19.03 15.44 36.68 13.25 27.94 26.60 50.41 23.61 40.3448 9.46 22.90 9.07 20.56 16.52 39.26 13.81 29.53 28.64 54.59 24.81 43.1949 10.08 25.32 9.62 22.21 17.67 42.03 14.39 31.22 30.82 59.11 26.07 46.2450 10.75 28.00 10.20 24.00 18.90 45.00 15.00 33.00 33.18 64.00 27.39 49.5051 11.92 31.04 10.93 25.70 19.99 48.13 15.69 35.11 36.27 68.84 29.86 53.3252 13.21 34.40 11.71 27.52 21.14 51.48 16.42 37.36 39.65 74.05 32.55 57.4453 14.65 38.13 12.54 29.47 22.35 55.07 17.18 39.75 43.34 79.65 35.49 61.8854 16.24 42.27 13.44 31.56 23.64 58.90 17.97 42.29 47.37 85.67 38.69 66.6555 18.00 46.85 14.40 33.80 25.00 63.00 18.80 45.00 51.78 92.15 42.18 71.8056 19.52 50.02 15.22 35.79 26.27 66.57 19.66 45.77 57.19 100.73 46.54 78.0657 21.17 53.41 16.09 37.90 27.59 70.35 20.56 46.56 63.16 110.11 51.36 84.8758 22.96 57.02 17.01 40.13 28.99 74.33 21.49 47.36 69.75 120.36 56.67 92.2759 24.90 60.88 17.98 42.50 30.46 78.55 22.47 48.17 77.04 131.57 62.53 100.3160 27.00 65.00 19.00 45.00 32.00 83.00 23.50 49.00 85.08 143.82 69.00 109.06

QUCI 07/2017www.wawanesalife.com

Toll Free: 1-888-997-9965®

® Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.

QUICK ISSUE CRITICAL ILLNESS

APPLICATION FOR QUICK ISSUE CRITICAL ILLNESS

®

1 of 6

GENERAL INFORMATION - INSURED

NAME (please print) Mr Mrs Miss Ms DATE OF BIRTH AGE SEX

M F

INSURED ADDRESS - Number, Street, City, Province POSTAL CODE

PHONE # SOCIAL INSURANCE NUMBER

( )

PLACE OF BIRTH: Province: Country:

OCCUPATION:

Has there been a change of name in the last five years? YES NO If ‘YES’: Are you a Canadian citizen or landed immigrant, currently residing in Canada? YES NO If ‘NO’, coverage is not available. GENERAL INFORMATION - POLICY OWNER, if other than Life Insured

NAME (please print) Mr Mrs Miss Ms DATE OF BIRTH AGE SEX

M F

POLICY OWNER ADDRESS - Number, Street, City, Province POSTAL CODE

PHONE # SOCIAL INSURANCE NUMBER

( )

POLICY OWNER OCCUPATION RELATIONSHIP TO INSURED

CONTINGENT POLICY OWNER RELATIONSHIP TO INSURED

DAY MONTH YEAR

DAY MONTH YEAR

LAST FIRST MIDDLE

LAST FIRST MIDDLE

NAME RELATIONSHIP TO INSURED

TRUSTEE (if beneficiary is under age 18)

CONTINGENT BENEFICIARY (if any) RELATIONSHIP TO INSURED

BENEFICIARY DESIGNATION

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Within the last 12 months, have you used any tobacco or nicotine products including cigarettes, YES NO cigarillos, colts, cigars, pipes, chewing tobacco, snuff, e-cigarettes, nicotine gum or patches, or any form of nicotine substitute?

TOBACCO USE

DETAILS OF POLICY BENEFITS

$Basic Amount

*Please complete Pre-Authorized Debit Agreement on page 4.

Semi-Annual Billing

PAYMENT OPTIONS (select one)

Monthly Pre-Authorized Debit (PAD)*Semi-Annual PAD*Annual PAD*

Annual Billing

POLICY DELIVERY OPTIONS

Policy should be mailed to: Policy Owner (direct delivery) or Independent Insurance Broker (personal delivery)

If no preference is indicated, the policy will be sent directly to the policy owner.

T10 Renewable to 75Level Term to 75Level Term to 75 / ROP

INDIVIDUALS: POLICY OWNER JOINT POLICY OWNER

Are you a U.S. citizen or a U.S. resident for U.S. tax purposes? YES NO YES NO If ‘Yes’, provide your U.S. Taxpayer Identification Number (TIN):

DECLARATION OF TAX RESIDENCE

ENTITIES: Please complete the Declaration of Tax Residence for Entities form available on the Broker Forms page of our website.

(if applicable)

a) U.S. CITIZEN OR RESIDENT

INDIVIDUALS: POLICY OWNER JOINT POLICY OWNER

Are you a tax resident of a jurisdiction other than Canada or the U.S? YES NO YES NO If ‘Yes’, give your jurisdictions of tax residence and Taxpayer Identification Number (TIN). If you do not have a TIN for a specific jurisdiction, give the reason using one of these choices:

Reason 1: I will apply or have applied for a TIN but have not yet received it. Reason 2: My jurisdiction of tax residence does not issue TINs to its residents. Reason 3: Other reason.

ENTITIES: Please complete the Declaration of Tax Residence for Entities form available on the Broker Forms page of our website.

(if applicable)

b) RESIDENT OF A COUNTRY OTHER THAN CANADA OR THE U.S.

Canadian financial institutions are required under Part XVIII and Part XIX of the Income Tax Act to collect the information you provide on this form to determine if we have to report your financial account to the Canada Revenue Agency (CRA). The CRA may share this information with the government of a foreign jurisdiction that a person identified on this form is a resident of for tax purposes. In the case of the United States, the CRA may also share the information with the U.S. government if the person is a U.S. citizen.

Jurisdiction of tax residence Taxpayer identification number If you do not have a TIN, choose reason 1, 2 or 3

Policy Owner

Joint Policy Owner

If reason 3 is selected, please specify:

4 of 6

QUALIFYING QUESTIONS

1. Within the last two years, have you had an application for individual life insurance or critical illness YES NO insurance rated, declined, postponed or had exclusions added by Wawanesa Life or any other company?

2. Have you ever been treated for, diagnosed, consulted a doctor, received abnormal test results or YES NO experienced symptoms of the following:

(a) Heart attack, congenital cardiac defects, angina, angioplasty, coronary artery bypass, congestive heart failure, stroke, transient ischemic attack (TIA), arteriosclerosis, or any other cerebrovascular disease or disease of the heart or the blood vessels, or an abnormal electrocardiogram (EKG)?

(b) Type 1 (insulin-dependent) diabetes or type 2 diabetes?

(c) Cancer or other malignant disease, growth, tumour or colon polyp?

(d) Multiple Sclerosis or motor neuron disease?

(e) Any breast disorders (mass, cyst, unusual discharge, physical change, abnormal mammogram or biopsy) or prostate disorders (nodule or abnormal PSA)?

(f) Any eye or ear problems or diseases other than corrected by glasses, contact lenses or hearing aids?

3. (a) Have you consulted a physician for an illness or condition which has not yet been diagnosed or for YES NO which testing is still in progress?

(b) Have you noticed any symptoms or health problems for which you have not yet consulted a physician, such as: lump or mass of the breasts, shortness of breath, chest pain, dizziness, loss of balance, numbness, rectal bleeding, prostate or other problems?

4. Have you ever tested positive for HIV or been diagnosed, treated for or had any indication of AIDS, YES NO AIDS related complex, liver or kidney failure, cirrhosis, chronic kidney disease, hepatitis B or C, or carrier of hepatitis B?

5. Within the last five years, have you received treatment or been advised to seek treatment or medical YES NO advice because of your alcohol usage?

6. Within the last five years, have you used: heroin, cocaine, hallucinogens or any other hard drugs other YES NO than as prescribed by a doctor, or methadone whether prescribed by a doctor or not, or have you received treatment or been advised to seek treatment or medical advice because of your drug usage?

7. To the best of your knowledge, has one of your natural parents or siblings ever suffered from, or are YES NO suffering from heart disease, cancer, stroke or transient ischemic attack (TIA) prior to the age of 55?

8. Does your current weight exceed the weight indicated in the maximum weight table below? YES NO

3 of 6

IF YOU ANSWERED ‘YES’ TO ANY OF THE ABOVE EIGHT QUESTIONS, COVERAGE IS NOT AVAILABLE.Note: Wawanesa Life reserves the right to carry out an assessment on factors other than the ones indicated above. Wawanesa Life also has a right to obtain a report from The Medical Information Bureau Inc. (MIB, Inc.) and, should this report be unfavorable, any premiums paid with the application will be refunded and coverage will not be in force during the investigation period.

4 of 63 of 6

PRE-AUTHORIZED DEBIT (PAD) AGREEMENT (if applicable) You, the Payor, authorize the Wawanesa Life Insurance Company to debit the bank account identified below for the amount, frequency and on withdrawal day indicated or the next business day. For provisions of this agreement, please see the Pre-Authorized Debit Plan Authorization section.

PAYMENT FREQUENCY (check one) TOTAL MODAL PREMIUM WITHDRAWAL DAY MONTHLY SEMI-ANNUAL ANNUAL $ POLICY DATE or (1ST - 28TH)

PAYOR INFORMATION (please print clearly)ACCOUNT OWNER NAME(S)* PHONE # ( ) -

STREET ADDRESS

CITY & PROVINCE POSTAL CODE

BANK ACCOUNT INFORMATION Use my current Wawanesa Life PAD under policy # or

Establish a new PAD using: Details from premium cheque (attached) Details from void cheque (attached) Information below:

FINANCIAL INSTITUTION (F.I.)

BRANCH ADDRESS

CITY & PROVINCE POSTAL CODE

TYPE OF ACCOUNT (must allow electronic debits) SAVINGS CHEQUING

TRANSIT NO. F.I. NO. ACCOUNT NO.

FOR EXECUTIVE OFFICE USE ONLY

PAD NO. WITHDRAWAL DAY

TOTAL PAD AMOUNT $

*NOTE: Account Owner’s Signature is required on page 6.

PRE-AUTHORIZED DEBIT (PAD) PLAN AUTHORIZATION (if applicable)I request and authorize Wawanesa Life to make withdrawals from the account designated on the Pre-Authorized Debit (PAD) Agreement or from any subsequently designated account in order to make policy payments and/or specific payments on loan indebtedness, under the following terms:

1. Withdrawals will be made according to the payment frequency indicated on the application on the policy issue date unless a particular withdrawal day is specified.

2. If a monthly PAD is returned as insufficient funds, the next PAD amount will be for the two months of premium. Notification will be provided prior to this double withdrawal.

3. I may revoke my authorization at any time, subject to providing written notice of 10 days to Wawanesa Life. (For more information on your right to cancel a PAD agreement, contact your financial institution or visit www.cdnpay.ca.)

4. I have certain recourse rights, provided under the personal PAD agreement, if any debit does not comply with the agreement. For example, I have the right to receive reimbursement for any debit that is not authorized or is not consistent with the personal PAD agreement. (For more information on your recourse rights, contact your financial institution or visit www.cdnpay.ca.)

5. I may provide written request to add/delete policies to the PAD agreement or change bank information without completing a new PAD agreement.

6. I waive the right to receive 10 days’ notice of an increase or decrease in the amount of the automatic withdrawal due to premium changes during the underwriting process. Notification of premium changes will be provided when the policy is issued.

plus sales tax, if applicable.

6 of 65 of 6

DECLARATIONS AND AUTHORIZATIONS I, the Insured/Policy Owner understand and agree that:

1. Once the policy is issued and received by the Policy Owner, the Policy Owner will inspect the policy to verify that its terms are satisfactory and as requested. If the policy is not returned to Wawanesa Life within 30 days from the date of the policy delivery letter, the Policy Owner accepts the policy.

2. No statement, representation or promise made in respect of the insurance applied for shall be deemed to have been communicated to or binding on Wawanesa life unless set out in this application.

3. No independent insurance broker is authorized to amend, alter, modify or waive the terms of this application, or any contract of insurance issued.

I declare that the statements and answers made in this application and in any supplement to this application are true, complete and correctly recorded and will form the basis of any contract issued.

I acknowledge having received the notices regarding The Medical Information Bureau Inc. (MIB, Inc.) and Investigative Reports, and consent to such reports being obtained by Wawanesa Life. Should an unfavorable report be obtained from The Medical Information Bureau Inc. (MIB, Inc.), any premiums paid with the application will be refunded and coverage will not be in force during the investigation period. I authorize Wawanesa Life, or its reinsurers, to make a brief report of my personal health information to The Medical Information Bureau Inc. (MIB, Inc.).

I authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company, The Medical Information Bureau, Motor Vehicle Department concerning my drivers abstract, or other organization, institution or person that has any records or knowledge of me or my health or of my children or their health to give Wawanesa Life or its reinsurer(s) any such information. I authorize Wawanesa Life to perform such tests, examinations, x-rays, electrocardiograms, urinalysis, general blood profiles including blood tests for AIDS as may be required to medically underwrite this application for insurance.

I authorize the Medical Director of Wawanesa Life to release all medically related information obtained during the underwriting process to my personal physician or other medical practitioner. I authorize Wawanesa Life to disclose information regarding the underwriting factors, if applicable, to my Wawanesa Life independent insurance broker.

CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION

I consent to Wawanesa Life collecting, using and disclosing my personal information for the purposes of: establishing and maintaining communications with me; underwriting risks on a prudent basis; investigating and paying claims; receiving payments of insurance premiums and policy loan repayments; withdrawing premiums from and depositing funds into my account (applicable if PAD Agreement is signed); detecting and preventing fraud; offering and providing products and services to meet my needs; compiling statistics and acting as required or authorized by law.

I have read and understood that Wawanesa Life may share my personal information with the required people, organizations and service providers as described in the Notice of Consent & Disclosure Regarding Personal Information on Customer Copy, who may be in other provinces or in jurisdictions outside Canada. My information may be shared as required by the laws of those jurisdictions.

I recognize that in providing services to me in the future and providing me with the benefits included in the policy I am applying for, Wawanesa Life may need to collect, use and disclose additional personal information about me. I confirm that this consent applies to that personal information as well.

I understand that any restriction or withdrawal of my consent may result in Wawanesa Life being unable to provide me with the product or service being applied for or having to terminate the policy.

You can obtain further information about Wawanesa Life’s Personal Information Protection Policy from the Wawanesa Life Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at www.wawanesalife.com.

If you have a question (including a question concerning our collection of personal information, or the collection, use, disclosure or storage of personal information by service providers outside Canada on our behalf) or complaint regarding our privacy policies and procedures, please contact the individual accountable for our personal information protection compliance: Senior Vice President, Chief Legal Officer & Corporate Secretary, The Wawanesa Life Insurance Company, 900-191 Broadway, Winnipeg, Manitoba R3C 3P1.

(SIGNATURES REQUIRED ON PAGE 6)

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ALLOCATION FACTORS1ST YEAR RENEWAL

ALLOCATION OF THIS SALE

% % AGENT OF RECORD (Please Print) BROKER NUMBER

% % SERVICING AGENT (Please Print) BROKER NUMBER

% % OTHER (Please Print) BROKER NUMBER

Signed at in the province of on this day of ,

INSURED (Signature) POLICY OWNER, if other than Insured (Signature)

PAD ACCOUNT HOLDERS, if other than Policy Owner or Insured WITNESS (Signature) (Signature)

I confirm that all of my answers to the declarations are truthful and complete to the best of my information, knowledge and belief. I further confirm that I have read, understood and accepted the terms and conditions of the agreements, declarations and authorizations in this application.

SIGNATURES - For Authorizations on pages 4 and 5

A photocopy or an electronic reproduction of this document will be as valid as the original.

SELLING BROKER (Please print) SELLING BROKER (Signature)

I declare that I have asked and fully recorded the answers of all proposed lives insured to all questions on this application, and that I know of nothing that is material to their insurability that has not been recorded herein. I am aware of and in compliance with the Company’s Sales Code of Ethics.

Confirming Disclosure: I have provided the applicant(s) with written materials advising: about the company(s) I currently represent, that I receive compensation (such as commissions or a salary) for the sale of life and health insurance products, that I may receive additional compensation in the form of bonuses or other incentives, and of any conflicts of interest I may have with respect to this transaction.

INDEPENDENT INSURANCE BROKER’S DECLARATION

The Wawanesa Life Insurance Company, 400 - 200 Main St, Winnipeg, MB R3C 1A8Phone: 1-204-985-3940 Toll Free: 1-800-263-6785 Toll Free Fax: 1-888-985-3872

QUCI 07/2017®

® Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.

CUSTOMER COPY

QUICK ISSUE CRITICAL ILLNESS

CUSTOMER COPY

®

INDEPENDENT INSURANCE BROKER PROCEDURES: THE FOLLOWING NOTICES & DISCLOSURES ARE INCLUDED ON THIS SHEET AND MUST BE GIVEN TO THE POLICY OWNER.

NOTICES & DISCLOSURE STATEMENTS

Notice of Medical Information Bureau Inc. (MIB, Inc.) This notice must be given to the Policy Owner.

Notice of Consent to Obtain & Release Medical/Underwriting Information This notice must be given to the Policy Owner.

Notice of Consent & Disclosure Regarding Personal Information This notice must be given to the Policy Owner.

Change in Insurability This notice must be given to the Policy Owner.

Independent Insurance Broker Disclosure Statement This section must be completed and signed by the selling independent insurance broker.

Receipt for Payment Receipt for Payment must be completed and given to the Policy Owner.

NOTICE OF MEDICAL INFORMATION BUREAU INC. (MIB, INC.)

Information regarding your insurability will be treated as confidential. We, or our reinsurers may, however, make a brief report thereon to MIB, Inc., a not-for-profit membership organization of insurance companies which operates an information exchange on behalf of its members. If you apply to another MIB, Inc. member company for life and health insurance coverage, or a claim for benefits is submitted to such a company, MIB, Inc., upon request, will supply such company with the information it may have in its file.

Upon receipt of a request from you, MIB, Inc. will arrange disclosure of any information it may have in your file. If you question the accuracy of information in MIB, Inc.’s file, you may contact MIB, Inc. and seek a correction in accordance with the procedures set forth in the federal Fair Credit Reporting Act. The address of MIB, Inc.’s information office is 330 University Avenue, Suite 501, Toronto, ON Canada M5G 1R7, telephone number (416) 597-0590.

We, or our reinsurers, may also release information in our file to other life insurance companies to whom you may apply for life and health insurance, or to whom a claim for benefits may be submitted.

NOTICE OF CONSENT TO OBTAIN & RELEASE MEDICAL/UNDERWRITING INFORMATION

In the processing of the application for insurance, The Wawanesa Life Insurance Company may obtain records, investigative or medical reports containing personal information about the individuals proposed for insurance.

As part of the underwriting process, the Medical Director of Wawanesa may need to release medically related information obtained during the underwriting process to your personal physician or other medical practitioner. We may also need to disclose information regarding the underwriting factors to your Wawanesa Life independent insurance broker.

APPLICATION FOR INSURANCE Customer Copy

NOTICE OF CONSENT & DISCLOSURE REGARDING PERSONAL INFORMATION

We collect, use and disclose your personal information in order to administer the products and services you have requested. Personal Information is collected for the purposes of: establishing and maintaining communications with you; underwriting risks on a prudent basis; investigating and paying claims; receiving payments of insurance premiums and policy loan repayments; withdrawing premiums from and depositing funds into your account (applicable if PAD Agreement is signed); detecting and preventing fraud; offering and providing products and services to meet your needs; compiling statistics and acting as required or authorized by law.

We may share your personal information with the following people, organizations and service providers: Wawanesa Life employees and independent insurance brokers who require this information to perform their jobs; third party providers who require this information to provide their services to you, which may include paramedical agencies, underwriters, claims investigators, investigative agencies, providers of information processing and storage, programming, printing, mailing and distributions services; applicable reinsurance companies to allow them to evaluate and administer any insurance risk that they accept; the Medical Information Bureau Inc. (MIB, Inc.) as explained in the notice provided; people to whom you have granted access; and people who are legally authorized to view your personal information. These people, organizations and service providers may be in other provinces or in jurisdictions outside Canada. Your information may be shared as required by the laws of those jurisdictions.

In order to provide services to you in the future and provide you with the benefits included in the policy, Wawanesa Life may need to collect, use and disclose additional personal information about you. We may not require you to provide consent at that time.

Any restriction or withdrawal of your consent may result in Wawanesa Life being unable to provide you with

the product or service being applied for or having to terminate the policy.

You can obtain further information about Wawanesa Life’s Personal Information Protection Policy from the Wawanesa Life Executive Office at 400-200 Main Street, Winnipeg, MB R3C 1A8 or at www.wawanesalife.com.

If you have a question (including a question concerning our collection of personal information, or the collection, use, disclosure or storage of personal information by service providers outside Canada on our behalf) or complaint regarding our privacy policies and procedures, please contact the individual accountable for our personal information protection compliance: Senior Vice President, Chief Legal Officer & Corporate Secretary, The Wawanesa Life Insurance Company, 900-191 Broadway, Winnipeg, Manitoba R3C 3P1.

Change in insurability includes: a change in occupation or lifestyle that would increase risks to the insured’s life or health; any change that would cause the insured to answer health or lifestyle questions differently than when they applied for the insurance; the diagnosis or identification of any health-related condition; and any pending or completed medical tests or exams.

If there is a change in insurability of any individual proposed for insurance subsequent to the completion of the application and prior to the date on the policy delivery letter mailed to the Policy Owner, The Wawanesa Life Insurance Company must be notified in order to properly evaluate the risk. If the change in insurability is not communicated and the Company is not given a chance to assess the risk, any policy issued pursuant to this application shall not take effect.

CHANGE IN INSURABILITY

INDEPENDENT INSURANCE BROKER DISCLOSURE STATEMENT

The following disclosure notice must be completed by the independent insurance broker and provided to you, in writing prior to you entering into this financial transaction. Please ask your independent insurance broker for further information or details.

1. I, , am a licensed insurance broker in the province of .

2. This transaction is between you and WAWANESA LIFE.

3. In soliciting this transaction, I am representing WAWANESA LIFE and .

4. In the past 12 calendar months, the majority of the insurance or financial products that I have sold were issued by the following companies: .

5. I am committed to selling on the basis of needs.

6. Upon completion of this transaction, I will receive compensation from WAWANESA LIFE and may receive additional compensation in the form of bonuses or other incentives.

7. The nature and extent of my relationship with WAWANESA LIFE is as an independent insurance broker.

8. I and WAWANESA LIFE are prohibited from requiring you to transact additional business with WAWANESA LIFE or any other person or corporation as a condition of this transaction.

9. I declare the following conflicts of interest, if any: .

SIGNATURE OF INDEPENDENT INSURANCE BROKER DATE

The Wawanesa Life Insurance Company, 400 - 200 Main St, Winnipeg, MB R3C 1A8Phone: 1-204-985-3940 Toll Free: 1-800-263-6785 Toll Free Fax: 1-888-985-3872 QUCI 07/2017

NAME OF AGENCY

RECEIPT FOR PAYMENT

RECEIVED $ for insurance applied for in an application with the same date as this receipt.

ON THE LIFE OF

SIGNATURE OF INDEPENDENT INSURANCE BROKER

DATE

® Wawanesa Life and the tree logo are registered trade-marks of The Wawanesa Mutual Insurance Company and used under license by The Wawanesa Life Insurance Company.

®