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PLEASE PRINT
Name
First
Street Address or RR#
City
Application to
EATON LIFE ASSURANCE COMPANY
for a
GUARANTEED LIFE PLAN
Middle
Last
Prov.
BirthDate -------------
D
Male
D
Female
Day
Month
Year
BENEFICIARY
Apt.No.Postal Code
Social Insurance No.
Name in Full
Relationship
Does this policy replace any other life insurance you now have?
D
Yes
D
No. If "Yes··, give name of company and plan number.
I hereby apply for enrollment in Eaton Life's Guaranteed Life Plan. I enclose my cheque or money order for $1 .00, and
understand that my policy will become effective the day my application, accompanied by the payment of $1 .00, is received by
Eaton Life Assurance Company's Head Office.
0
Check here if you wish to DOUBLE THE COVERAGE of your plan.
Your monthly premium for DOUBLE COVERAGE will be $14.95.
Applicanrs Signature
022
Cheque or money order for $1.00 must accompany application.
Make cheques payable to: Eaton Life Assurance Company
4 Ways to pay your premiums (choose one method only)
1
0
EATON ACCOUNT PLAN (monthly only)
Available to all Eaton Account holders. You can pay the monthly premium on your Eaton Account. Just complete the
authorization below:
I authorize The
T.
Eaton Co.Limited to pay monthlypremiums to EatonLifeAssuranceCompany (the initialbilling will
cover 2 months' premiums) and to charge my Eaton Account.
Account No.
Authorized Signature
2
0
PRE-AUTHORIZED CHEQUE PLAN (monthly only)
I would like to pay monthly by automatic deduction from my bank account. Please send the authorization form with my
policy.
3
0
QUARTERLY-PAY DIRECT PLAN
Eaton Life will bill you directly, every three months. The premium will be 3 times the applicable monthly premium.
4
0
ANNUAL - PAY DIRECT PLAN
Eaton Life will bill you directly, once a year. The premium will be 12 times the applicable monthly premium.
MAIL APPLICATION TO:
Eaton Life Assurance Company
Head Office: 14 College Street Toronto, Ontario MSG 1K4
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You can charge your premiums
to your Eaton Account.
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LIFE
Family
Protection