Fillable Health statement Keeping your information confidential (Sun Life Canada)

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Health statement Keeping your information confidential (Sun Life Canada)

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Page 1 of 4
3484-Basic-Opt-CI-MSD-A-E-03-16
Health statement
1 | Plan administrator information (to be completed by the plan administrator or the member)
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 Member ID
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 plan member with information provided by the plan administrator.
• Plan member to mail form directly to Sun Life Assurance Company of Canada.
Please PRINT clearly.
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)
– –
Male
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
 Day  Evening
– –
Business telephone number  Day  Evening
– –
Preferred method of contact  Mail  Email
Email address: ___________________________________________________
Height
ft. in.
m cm
Weight lbs.
kg
Change in weight in the last 12 months lbs.
No change Gain _________ Loss ________
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
Clear
Page 2 of 4
3484-Basic-Opt-CI-MSD-A-E-03-16
2 | Member and dependent details (continued)
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)
– –
Male
Female
Height
ft. in.
m cm
Weight lbs.
kg
Change in weight in the last 12 months lbs.
No change Gain _________ Loss ________
kg
Reason for weight change
Date, reason and results for your dependent’s 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 dependent’s medical history, please provide full name and address of the doctor who does have them
Child’s last name Child’s first name
Date of birth (dd-mm-yyyy)
– –
Male
Female
Height
ft. in.
m cm
Weight lbs.
kg
Child’s last name Child’s first name
Date of birth (dd-mm-yyyy)
– –
Male
Female
Height
ft. in.
m cm
Weight lbs.
kg
Child’s last name Child’s first name
Date of birth (dd-mm-yyyy)
– –
Male
Female
Height
ft. in.
m cm
Weight lbs.
kg
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? Yes No
Yes No
If yes, complete chart below.
Plan 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)
Page 3 of 4
3484-Basic-Opt-CI-MSD-A-E-03-16
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 Child(ren)
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? Yes No Yes No Yes No
b) Received disability benefits for three months or longer? Yes No Yes No Yes 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) Yes No Yes No Yes No
2. Have you used any tobacco products within the last 12 months? Yes No Yes No Yes 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)? Yes No Yes No Yes No
4. Do you consume alcoholic beverages? Yes No Yes No Yes 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?
Yes No Yes No Yes 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) Yes No Yes No Yes No
6. Have you ever had diabetes, impaired sugar levels or ever had sugar, blood
or protein in your urine?
Yes No Yes No Yes No
What is your current treatment for diabetes? Insulin: Yes No Yes No Yes No
Oral medication: Yes No Yes No Yes No
Diet only: Yes No Yes No Yes 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? Yes No Yes No Yes No
b) Illnesses of the heart or circulatory system, including chest pain, abnormal electrocardiogram
(ECG), irregular pulse, heart murmur? Yes No Yes No Yes No
c) Liver disorder or any type of hepatitis or blood disorders? Yes No Yes No Yes No
d) Disease or disorder of the kidneys, urinary tract, bladder, prostate or reproductive organs? Yes No Yes No Yes No
e) Chronic lung or respiratory disorder (including asthma and sleep apnea), disease or disorder of
the eyes, ears, nose or throat? Yes No Yes No Yes 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? Yes No Yes No Yes No
g) Psychiatric or psychological problems (including anxiety, depression, panic attacks, eating
disorders, any other emotional disorders) or been counselled for such? Yes No Yes No Yes No
h) Chronic fatigue syndrome, fibromyalgia, rheumatic/arthritic disease or lupus? Yes No Yes No Yes No
i) Musculoskeletal, joint or bone disorders, paralysis or numbness? Yes No Yes No Yes No
j) Back and neck problems? Yes No Yes No Yes No
k)
High blood pressure? Yes No Yes No Yes No
l)
High cholesterol? Yes No Yes No Yes No
m)
Gastrointestinal disorder (including esophageal, stomach, colon, colitis or bowel/intestinal disorders)?
Yes No Yes No Yes No
8. Have you ever tested positive for AIDS, ARC or HIV? Yes No Yes No Yes No
9. Have you ever suffered a heart attack or myocardial infarction? Yes No Yes No Yes No
10. Have you ever had a stroke? Yes No Yes No Yes No
11. Have you ever had an organ transplant? Yes No Yes No Yes No
12. Have you ever had any other illness, disease or disorder, condition, injury, diagnostic testing or
surgical
procedure not listed above? Yes No Yes No Yes 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? Yes No Yes No Yes 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)? Yes No Yes No Yes 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? Yes No Yes No
Yes No
Page 4 of 4
3484-Basic-Opt-CI-MSD-A-E-03-16
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/Children
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, the spouse and the child(ren) age 18 and older 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 dependents under age 18 (if applicable), pertaining to this Health statement. This includes any health professionals,
institutions, investigative agencies, insurers and reinsurers.
If I am a spouse or dependent age 18 and older, 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
X
Date (dd-mm-yyyy)
– –
Signature of spouse
X
Date (dd-mm-yyyy)
– –
Signature of dependent child 18 years or older
X
Date (dd-mm-yyyy)
– –
Signature of dependent child 18 years or older
X
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.
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Health statement Keeping your information confidential (Sun Life Canada)

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Completed 24 February 2022

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