Group Benefits
Non-smoking Declaration
The Manufacturers Life Insurance Company GL1715E (04/2007)
Plan member's signature Date signed (dd/mmm/yyyy)
3 Signature and
authorization
This designation must be
signed and dated to be valid.
To be completed by the plan member/spouse. In order to qualify for reduced non-smoker optional benefit rates, smoking materials (i.e.,
cigarettes, cigars, pipes, etc.) or tobacco in any other form must not have been used within the last 12 months. If you qualify, complete this
form and return to your plan sponsor.
I certify that I (being the plan member, spouse or dependant with the capacity to contract, whichever is applicable)
am applying for this Group Benefits coverage/insurance ("Coverage") and that the information provided for this
application is true and complete. I
agree that my coverage may be denied or terminated at any time as a result of
any false, incomplete, or misleading information having been provided in this application. I
authorize Manulife
Financial ("Manulife") to collect, use, maintain and disclose my personal information relevant to this application
("Information") for the purposes of Group Benefits plan administration, audit and the assessment, investigation, or
management of this application, and medical underwriting (collectively, the "Purposes"). I
am authorized to consent
to the collection, use, maintenance, exchange and disclosure of Information pertaining to any minor child who may
be the subject of this application for Coverage, for the Purposes, and all of the statements made herein on my own
behalf shall apply equally to such minor child. I
understand that Manulife may investigate this application and may
require Information about me for the Purposes, including information regarding activities, income, employment,
education and training, health and medical history and treatment, including clinical notes. I
authorize any person or
organization with Information, including any medical and health professionals, facilities or providers, professional
regulatory bodies, any employer, group plan administrator, insurer, investigative agency, and any administrators of
other benefits programs to collect, use, maintain and exchange this information with each other and with Manulife, its
reinsurers and/or its service providers, for the Purposes. I
understand that any Coverage shall not become effective
until approved by Manulife. I
authorize the use of my Social Insurance Number ("SIN") for the purposes of
identification and administration, if my SIN is used as my plan member certificate number. I
agree a photocopy or
electronic version of this authorization is valid. I
acknowledge that more specific details regarding how and why
Manulife collects, uses, maintains, and discloses my personal information can be found in Manulife's Privacy Policy
and Privacy Information Package, available at www.manulife.ca/groupbenefits, or from my Plan Sponsor.
Any Information provided to or collected by Manulife in accordance with this authorization, will be kept in a Group
Benefits life, health or disability file. Access to your Information will be limited to:
Manulife employees, representatives, reinsurers, and service providers in the performance of their jobs;
Persons to whom you have granted access; and
Persons authorized by law.
You have the right to request access to the personal information in your file, and, where appropriate, to have any
inaccurate information corrected.
Spouse's signature Date signed (dd/mmm/yyyy)
4 Mailing instructions
Please send your completed form to:
Plan Member Administration
Manulife Financial
PO BOX 2026
HALIFAX NS B3J 2Z1
1
Plan contract number Plan member certificate number
Plan member
information
Plan sponsor name
Province of residence
Plan member name (last, first and middle initial)
2 Declaration
Complete only if you have
spousal coverage.
Spousal information
Name of spouse
I, the plan member/spouse, hereby declare that:
I have not smoked any cigarettes, cigars, pipes or used tobacco in any form within the last TWELVE months.
my spouse has not smoked any cigarettes, cigars, pipes or used tobacco in any form within the last
TWELVE months.
50231
Saint Mary's University
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