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7. COMPLETE FOR DEPENDANT LIFE CLAIMS ONLY
1-800-565-0701 | SISIP.com
SISIP Financial 7E (05/2021)
Protected “B” (when completed)
Was the dependant:
a Student?
Yes
No Full-time Part-time
Dated at this day of 20 .
Employed? Yes No Full-time Part-time
Dependent on you for nancial support? Yes* No
Married? Yes No
10. SIGNATURE (to be read and signed for all submissions)
9. EMAIL CONSENT (if applicable)
Declaration and authorization by claimant
The responses and declarations contained herein are true and complete. I realize that any
material misrepresentation will render void this claim. I hereby authorize SISIP Financial
and Manulife or its reinsurers, for underwriting and administration of insurance and claims
paying purposes only:
a) I understand the completion of this form is not an admission of any liability on the part
of SISIP Financial or Manulife;
b) to gather only that information necessary for the object of the le, from any person
or organization that has personal information relating to me, including other
insurers, physicians and medical institutions, the Medical Information Bureau (MIB*),
investigation and credit reporting agencies, and all persons or organizations likely to
have personal information relevant to the object of the le;
c) to disclose only the necessary personal information it has relating to me to these same
persons and organizations, specied in paragraph (a); or,
d) to request a personal investigation report relating to me.
A copy of this authorization shall be as valid as the original. This authorization is valid for
the period required to achieve the ends for which it was requested.
The information provided on this form is protected from unauthorized disclosure under
Canada’s Privacy Act, Personal Information Protection and Electronic Documents Act (PIPEDA)
or equivalent provincial legislation and is available to you upon request.
I would like to correspond by email with Manulife about my claim. I authorize Manulife to correspond with me at the email address listed in Block 3.
Correspondence may contain my personal information including, but not limited to, medical, employment and nancial information.
Claimant’s
Signature:
Claimant’s
Name Printed:
Yes Initials:
No
8. DECEASED’S PHYSICIAN INFORMATION
Names and addresses of all physicians, other than military medical ocers, who attended the deceased during the last three years.
Name Address Telephone Fax
Father’s rst
and last name:
Mother’s rst
and last name:
11. SISIP FINANCIAL REPRESENTATIVE who assisted in the completion of and/or reviewed this form
dd mm yyyyName Signature
Branch
*If Yes, please provide proof of the nancial support with this claim.
(i.e., conrmation of coverage under the member’s medical/dental benets plan, etc.)
*MIB - to review information on your le, or have it corrected, visit www.mib.com for contact information.
