Fill - Free fillable 3484 Basic Opt CI MS E PDF form

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3484-Opt-CI-MS-E-01-12

Health statement

1 | Plan administrator information (to be completed by the plan administrator or the member)

Keeping your information confidential

Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies, is committed to keeping your information

confidential. We may leverage our strengths in our worldwide operations and in our negotiated relationships with third-party providers

and reinsurers who, in some instances, may be located in jurisdictions outside Canada. Your personal information may be subject to the

laws of those foreign jurisdictions. Sun Life Financial’s operations worldwide and our third-party providers are required to protect the

confidentiality of your personal information in a manner that is consistent with our privacy policy and practices.

To find out about our Privacy Policy, visit our website at www.sunlife.ca, or to obtain information about our privacy practices, send a written

request by email to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.

Important

• Incomplete forms will delay processing.

• Part 1 is to be completed by the plan administrator or the member with information provided by the plan administrator.

• Member to mail form directly to Sun Life Assurance Company of Canada.

Please PRINT clearly.

Coverage is not in effect until you receive notice of approval from Sun Life Assurance Company of Canada.

Member’s last name Member’s first name Contract number

Occupation Class Billing group Member ID

Current salary m Hrly. m Wkly. m Bi-Wkly.

$ m Mthly. m Ann.

Company name Plan administrator’s name

Company street address City Province Postal code Telephone number

– –

Reason for application

m New enrolment – effective date (dd-mm-yyyy)

– –

m Increased coverage

m Late applicant (enrolled after 31 days)

m Re-application (previously declined)

m Annual enrolment – effective date (dd-mm-yyyy)

– –

Benefits requested A. Existing amount of coverage B. New amount of coverage C. Total amount of coverage

(Please check off) (if applicable) requested (A + B)

m Optional Life – member

m Optional Life – spouse

m Critical Illness – member

m Critical Illness – spouse

Clear

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3484-Opt-CI-MS-E-01-12

2 | Member and dependent details (to be completed by the member)

2.1 General information about the member

Member’s last name Member’s first name

Date of birth (dd-mm-yyyy)

– –

m Male

m Female

Member’s street address (street number and name) Apartment or suite City Province Postal code

Please provide all applicable contact information where you can be reached for additional information

Home telephone number

m Day m Evening – –

Business telephone number

m Day m Evening – –

Email address

Height

ft. in.

m cm

Weight m lbs.

m kg

Change in weight in the last 12 months m lbs.

m No change m Gain _________ m Loss ________ m kg

Reason for weight change

Date and reason for your last consultation with attending doctor (if no attending doctor, please state none)

Name of doctor, diagnosis, treatment given, results, medication prescribed

If the doctor named above does not have the most complete records of your medical history, please provide full name and address of the doctor who does have them

2.2 General information about the member’s dependents (complete this section only if applying for dependent coverage)

Spouse’s last name Spouse’s first name

Date of birth (dd-mm-yyyy)

– –

m Male

m Female

Height

ft. in.

m cm

Weight m lbs.

m kg

Change in weight in the last 12 months m lbs.

m No change m Gain _________ m Loss ________

m kg

Reason for weight change

Date, reason and results for your last consultation with attending doctor (if no attending doctor, please state none)

Name of doctor, diagnosis, treatment given, results, medication prescribed

If the doctor named above does not have the most complete records of your medical history, please provide full name and address of the doctor who does have them

2.3 Family history information

Have any of your or your spouse’s immediate family members (parents, brothers, sisters) had heart disease, heart Member Spouse

attack, high blood pressure, polycystic kidney disease, familial polyposis of the bowel, stroke, diabetes, cancer

(specify type below), multiple sclerosis, Huntington’s Chorea, Alzheimer’s, Parkinson’s, ALS (Amyotrophic Lateral

Sclerosis) or any hereditary disease? m Yes m No m Yes m No

If yes, complete chart below.

Member’s family history

Which condition(s) Age at onset

Current age (if living)

Age at death

(if applicable)

Father

Mother

Brother(s)

Sister(s)

Spouse’s family history

Which condition(s) Age at onset

Current age (if living)

Age at death

(if applicable)

Father

Mother

Brother(s)

Sister(s)

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3484-Opt-CI-MS-E-01-12

2 | Member and dependent details (continued)

2.4 Medical information (complete this section only for person(s) applying for insurance)

Complete section(s) 2.4, 2.5 and/or 2.6, as applicable, with any additional comments to these questions.

If you answer “yes” to any questions, please provide further details on the next page. Include dates, treatment, medications and results.

Member Spouse

1. Have you ever:

a) Been admitted to a hospital or clinic as a patient (except for pregnancy or birth) for longer than

five consecutive days? m Yes m No m Yes m No

b) Received disability benefits for three months or longer? m Yes m No m Yes m No

c) Been declined or offered Life, Disability or Critical Illness insurance at a higher than standard risk?

(If yes, specify name of insurer, date and reason) m Yes m No m Yes m No

2. Have you used any tobacco products within the last 12 months? m Yes m No m Yes m No

3. Within the last 10 years, have you used cocaine, hashish, heroin, narcotics, marijuana, LSD,

hallucinogens, amphetamines, except as prescribed by a doctor, or sought or received advice or

treatment for the use of drugs (over-the-counter, prescribed or non-prescribed)? m Yes m No m Yes m No

4. Do you consume alcoholic beverages? m Yes m No m Yes m No

a) Average number of drinks per week ___________ ___________

b) Have you ever been advised to stop drinking, to drink less or received treatment for the use of alcohol? m Yes m No m Yes m No

Who _______________________________________________________

(e.g. spouse, friend, doctor, etc.)

Reason _________________________________________ Date (dd-mm-yyyy) _________________________

5. Are you presently under medical treatment by diet, medicine or other means? (provide details

including names of all medications and reason(s) why you are using them) m Yes m No m Yes m No

6. Have you ever had diabetes, impaired sugar levels or ever had sugar, blood

or protein in your urine?

m Yes m No m Yes m No

What is your current treatment for diabetes? Insulin: m Yes m No m Yes m No

Oral medication: m Yes m No m Yes m No

Diet only: m Yes m No m Yes m No

7. Have you ever had or received treatment for, consulted a doctor or other health practitioner for, or

been diagnosed as having any one of the following:

a) Cancer, malignancy, leukemia, enlarged lymph nodes, lymph gland disorder, tumours, polyps or

other growths including moles, breast lumps or cysts, had a biopsy for any reason or had an

abnormal cancer screening test? m Yes m No m Yes m No

b) Illnesses of the heart or circulatory system, including chest pain, abnormal electrocardiogram

(ECG), irregular pulse, heart murmur? m Yes m No m Yes m No

c) Liver disorder or any type of hepatitis or blood disorders? m Yes m No m Yes m No

d) Disease or disorder of the kidneys, urinary tract, bladder, prostate or reproductive organs? m Yes m No m Yes m No

e) Chronic lung or respiratory disorder (including asthma and sleep apnea), disease or disorder of

the eyes, ears, nose or throat? m Yes m No m Yes m No

f) Transient ischemic attack (TIA), paralysis, seizure, epilepsy, multiple sclerosis, Alzheimer’s,

Parkinson’s or any other disease or disorder of the brain or nervous system? m Yes m No m Yes m No

g) Psychiatric or psychological problems (including anxiety, depression, panic attacks, eating

disorders, any other emotional disorders) or been counselled for such? m Yes m No m Yes m No

h) Chronic fatigue syndrome, fibromyalgia, rheumatic/arthritic disease or lupus? m Yes m No m Yes m No

i) Musculoskeletal, joint or bone disorders, paralysis or numbness? m Yes m No m Yes m No

j) Back and neck problems? m Yes m No m Yes m No

k) High blood pressure? m Yes m No m Yes m No

l) High cholesterol? m Yes m No m Yes m No

m) Gastrointestinal disorder (including esophageal, stomach, colon, colitis or bowel/intestinal disorders)? m Yes m No m Yes m No

8. Have you ever tested positive for AIDS, ARC or HIV? m Yes m No m Yes m No

9. Have you ever suffered a heart attack or myocardial infarction? m Yes m No m Yes m No

10. Have you ever had a stroke? m Yes m No m Yes m No

11. Have you ever had an organ transplant? m Yes m No m Yes m No

12. Have you ever had any other illness, disease or disorder, condition, injury, diagnostic testing or

surgical

procedure not listed above? m Yes m No m Yes m No

13. Have you ever used any special medical equipment or appliances such as a walker, cane, wheelchair,

catheter, oxygen tank, pacemaker, artificial limb or hearing aid? m Yes m No m Yes m No

14. Do you require assistance of any kind to perform any daily activities, such as bathing, continence,

dressing, eating, using the toilet or transferring (for example: bed to chair)? m Yes m No m Yes m No

15. Have you ever had any health symptoms or complaints for which a doctor has not been consulted

or been advised to have further examinations or tests which have not been completed yet? m Yes m No m Yes m No

– –

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2 | Member and dependent details (continued)

If you answered yes to any questions in the previous section, please provide further details. Use a separate sheet of paper if you need more

space but ensure all additional sheets are signed, dated and stapled to this form.

2.5 Additional medical details – Member

Question Further details

2.6 Additional medical details – Dependent Spouse

Question Dependent name Further details

3 | Declaration and authorization (please read and sign this section)

In this declaration and authorization, “I” applies to each of the member and the spouse signing below.

I understand I may be refused those group benefits or any benefit amounts for which proof of good health is required if, in the opinion of

Sun Life Assurance Company of Canada, I am not insurable. I certify that all the statements in this form are true and complete and I

understand that concealment, misrepresentation and false declaration concerning this Health statement, will cause the insurance to be void.

I authorize Sun Life Assurance Company of Canada, its agents and service providers to collect, use and disclose information needed for

underwriting, administrating and adjudicating claims under this Plan with any person or organization who has relevant information about

me and/or my spouse (if applicable), pertaining to this Health statement. This includes any health professionals, institutions, investigative

agencies, insurers and reinsurers.

If I am a spouse, I also authorize Sun Life Assurance Company of Canada to disclose information about this application to the member, for

the purposes of assessing this application and managing the group benefits plan.

I agree that a photocopy of this authorization or electronic version is as valid as the original and shall continue to have effect throughout the

duration of my coverage under this group contract, unless withdrawn in writing.

Signature of member

Date (dd-mm-yyyy)

– –

Signature of spouse

Date (dd-mm-yyyy)

– –

Sun Life Assurance Company of Canada must receive your completed Health statement within 60 days of the date you complete, sign and

date the form, otherwise you will need to submit a new Health statement.

All information received by Sun Life Assurance Company of Canada is treated as strictly confidential and is used for the sole purpose of

determining your eligibility and administering the group plan to which you belong. Returning your forms and medical information to us in

a confidential envelope ensures that only our medical underwriters will have access to them. Please fully complete the address.

Send the completed form to one of the following addresses in an envelope marked “Confidential” and retain a copy for

your records.

Toll-free fax number: 1-877-897-5519 Toll-free fax number: 1-877-897-6605

Sun Life Assurance Company of Canada Sun Life Assurance Company of Canada

Medical Underwriting Medical Underwriting

Private and Confidential Private and Confidential

PO Box 11691 Stn CV PO Box 578 Stn Waterloo

Montreal QC H3C 3J9 Waterloo ON N2J 4B8

Toll-free number 1-866-882-0884

Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.

Fill Online, Printable, Fillable, Blank 3484 Basic Opt CI MS E Form

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Fillable 3484 Basic Opt CI MS E

Fill Online, Printable, Fillable, Blank 3484 Basic Opt CI MS E Form

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