IA Clarington Investments Inc.

1 Use this Segregated Fund investment Application to open one of the following contracts: Non- registered (cash/open contract)Retirement Savings Plan (RSP)Retirement Income Fund (RIF)Locked-in Retirement Account (LIRA/LRSP)Restricted Locked-in RSP (RLSP)Life Income Fund (LIF)Locked-in Retirement Income Fund (LRIF)Restricted Life Income Fund (RLIF)Prescribed Retirement Income Fund (PRIF)IA Clarington GIF INDIVIDUAL VARIABLE ANNUITY CONTRACT Questions? Please contact us at remember to:1. Select your funds and fill in the amount to be Include your SIN number in section Attach a void cheque or direct deposit form for section 8, if Sign the investment application in section 10 and section make cheques payable to IA Clarington Investments Inc. Mail to: IA Clarington Investments Inc., c/o IFDS 1-30 Adelaide St. E., Toronto, ON M5C 3G9 Fax this application to: by Industrial Alliance Insurance and Financial Services Inc.

2 Administered by IA Clarington Investments by Industrial Alliance Insurance and Financial Services Inc. Administered by IA Clarington Investments Clarington Investments copy to IA Clarington Investments Inc. Blue copy to dealer. Carbon white copy to Contract | December 2017 21. REGISTRATION INFORMATIONMANDATORY New contract Existing contract # Transfer from existing IAC contract #2. PLAN TYPEMANDATORY for all contracts. Non- registered Plan - IndividualRegistered retirement savings plan (RRSP) Individual Spousal Locked-in retirement account (LIRA) Locked-in RIF (LRIF) Non- registered Plan - Joint Life Income Fund (LIF) Prescribed RIF (PRIF) SK & MB only Non- registered Plan - In Trust For Restricted LIF (RLIF) FED only Restricted LSP (RLSP) FED onlyRegistered retirement income fund (RRIF) Individual Spousal Non- registered Plan - Formal TrustPension jurisdiction: Non- registered Plan - Corporate3.

3 FINANCIAL ADVISOR INFORMATIONMANDATORY Dealer and advisor information complete this section for all advisor s full name Advisor code/number Telephone number Fax numberDealer name Dealer code/number Advisor email address4. APPLICANT INFORMATIONMANDATORY Language preference: English FrenchA. Primary planholder information Mr. Mrs. Ms. Miss Dr. Corporation (Attach Corporate Resolution) Formal Trust (attach Trust Documents)Last name First name Initial(s)Name of corporation/formal trust (Mandatory for a non- registered contract) Principal occupation (Be specific. Generic terms such as "manager" or " consultant" are not sufficient.) Address City Province Postal codeResidence phone number Business phone number Secondary planholder information Spousal Contributor (For Spousal RSP and RIF only) Joint with rights of survivorship (Not applicable to Quebec)**Who can provide authorization to make changes or place trades?

4 In Trust For (not applicable for registered plans or Quebec residents) Joint Tenants in Common* All accountholders must sign Any accountholder can signLast name First name Initial(s)AddressCityProvince Postal code Check here if you have attached a separate sheet with additional joint owner or In Trust For Trust For Accounts: Social Insurance Number to be used for tax reporting - Primary account owner (default) In trust forC. Annuitant information MANDATORY for ALL non- registered annuitant is the: Same as primary policyholder (section 4A) Same as joint holder (section 4B)If this section is not completed, the primary policyholder named in section 4A will be deemed to be the annuitant. For registered contracts, the annuitant must be and will be the primary policyholder named in section 4A. If the contract is held in a registered nominee or intermediary contract, the annuitant is automatically the registered nominee or intermediary contract holder.

5 Mr. Mrs. Ms. Miss name First name Initial(s)AddressCityProvince Postal codeIA Clarington Segregated Fund Individual Annuity Variable ContractIssued by Industrial Alliance Insurance and Financial Services by IA Clarington Investments of birth (DD/MM/YYYY)Social insurance number/ Business ID numberMANDATORYDate of birth (DD/MM/YYYY)Social insurance numberMANDATORYDate of birth (DD/MM/YYYY)Social insurance numberMANDATORYW hite copy to IA Clarington Investments Inc. Blue copy to dealer. Carbon white copy to Contract | December 2017 35. BENEFICIARY DESIGNATIONOPTIONAL This section is only for contracts held in client s any other beneficiary designation, for a contract held in client name and if the applicant acts as mandatory, trustee, or tutor or guardian, the beneficiary of the contract is the legal heir. However, if the contract is held in a registered nominee or intermediary contract, the beneficiary of the contract is automatically the trustee of the registered nominee or intermediary contract for the benefit of the holder of the registered nominee or intermediary contract.

6 For a contract held in a nominee or intermediary contract ( registered or non- registered ), any death benefit will be paid to the nominee or intermediary in trust for the beneficiary of the policyholder reserves the right to revoke the beneficiary, unless the beneficiary designated is irrevocable. Written consent of irrevocable beneficiary is required for certain plan plans: Your spouse may be automatically entitled to benefits under a LIRA, a LIF or any locked-in contracts (see section 2) notwithstanding the beneficiary residents: If you name your spouse or civil union spouse as a beneficiary, the designation is considered irrevocable unless you check the box indicating that it is : The beneficiary shares allocation will be split equally if not beneficiary s full nameDate of birth (DD/MM/YYYY) Social insurance numberRelationship to primary ownerShares %Designation% Revocable Irrevocable% Revocable IrrevocableIrrevocable beneficiary authorization MANDATORY if "Irrevocable" designation is indicatedNote.

7 Future beneficiary designation can not be changed by the policyholder without the irrevocable beneficiary's of irrevocable beneficiary Date (DD/MM/YYYY)Check here if you have attached a separate sheet with additional primary beneficiary beneficiary applicable if only ONE primary beneficiary is beneficiary s full nameDate of birth (DD/MM/YYYY) Social insurance numberRelationship to primary ownerCheck here if you have attached a separate sheet with additional contingent beneficiary investment INSTRUCTIONSMANDATORY for purchases and transfers ( T2033, T2151). Transfer from another institution (Attach a copy of the transfer form) One time PAC (Pre-authorized Contribution) (Withdraw directly from a bank account) VOID CHEQUE REQUIRED Amount: $ Upon receipt of this application in good order. Specify date (DD/MM/YYYY) One-time purchase: If no date is provided, IAC will process the one time purchase on the next available trade date after reception of the request in good order numberFund codeInvestment amountAmount $ or %Front End Sales charge 0 5%Default is 0% if left here if you have attached a separate sheet with additional investment SYSTEMATIC PLANSOPTIONAL VOID CHEQUE REQUIREDA.

8 PAC Pre-authorized cheque payment (only applicable for non- registered and RSP contracts)i. Start date: ii. Frequency Monthly* Every other month Quarterly Semi-annually Annually Twice monthly (Provide 2 dates)**1st start date: 2nd start date: Weekly Every other weekChoose the day of the week: Mon. Thurs. Tues. Fri. the applicant(s) of the account have read and acknowledge the pre-authorized debit agreement at the back of this application. * If monthly frequency is selected and no start date is provided we will default your run date to the 15th of the month. **If twice monthly frequency is selected and the 2nd start date is not provided, we will default your 2nd run date to 15 days following the date provided.(DD/MM/YYYY)iii. PAC allocationFund codeAmount Total: $ % $Sales chargefront-end* (0-5%)Must = 100% of amount*FE = 0% unless stated otherwiseWhite copy to IA Clarington Investments Inc.

9 Blue copy to dealer. Carbon white copy to Contract | December 2017 4B. SWP Systematic withdrawal plan (only applicable for non- registered contracts)i. Start date: ii. Frequency Monthly* Every other month Quarterly Semi-annually Annually Twice monthly (Provide 2 dates)**1st start date: 2nd start date: Weekly Every other weekChoose the day of the week: Mon. Thurs. Tues. Fri. Wed.*If monthly frequency is selected and no start date is provided we will default your run date to the 15th of the month. **If twice monthly frequency is selected and the 2nd start date is not provided, we will default your 2nd run date to 15 days following the date SSP Systematic switch plan (for automatic switches between funds within your contract)i. Start date: ii.

10 Frequency Monthly* Every other month Quarterly Semi-annually Annually Twice monthly (Provide 2 dates)**1st start date: 2nd start date: Weekly Every other weekChoose the day of the week: Mon. Thurs. Tues. Fri. : No switches available between USD and CDN units or between different sales charge option, such as DSC securities to low load securities and vice versa. Automatic switches are not allowed for free unit switches into front end sales charge option. *If monthly frequency is selected and no start date is provided we will default your run date to the 15th of the month. **If twice monthly frequency is selected and the 2nd start date is not provided, we will default your 2nd run date to 15 days following the date BANKING INFORMATIONMANDATORY if section 6 (one time PAC), 7A, 7B or 9 (EFT payment) is completed. Please attach void cheque or direct deposit form or existing bank account information on iA Clarington account - Account # IMPORTANT: If attached banking information does NOT contain the iA Clarington accountholder s name, please complete below RIF PAYMENT PLANA pplicable only to RIF, LIF, LRIF, RLIF, PRIF Start date If this section is not completed the default option will be the minimum payment based on your ACB paid annually on the 1st of Whose age is the minimum amount based on?