940-3300-05-18
Non smoking declaration
Please PRINT clearly.
1 Plan member details
Plan member’s last name First name
Contract number Location/billing group name Member ID number
Spouse’s last name (if applicable) First name
2 Declaration and authorization
Please select the appropriate box.
Member and/or Spouse must complete and sign if applicable.
Member
Have you used any nicotine products (tobacco, e-cigarettes, patches, etc) within the last 12 months?
Yes No
Spouse (if applicable)
Have you used any nicotine products (tobacco, e-cigarettes, patches, etc) within the last 12 months?
Yes No
I declare that the information above is accurate and true. Inaccurate information may invalidate my claim.
I authorize Sun Life Assurance Company of Canada, its agents and services providers, its reinsurers and their service providers
to collect, use and disclose information provided by me in this form to underwrite, administer and adjudicate claims under
the plan. A photocopy or electronic version of this authorization is as valid as the original.
Member’s signature
X
Date (yyyy-mm-dd)
Spouse’s signature (if applicable)
X
Date (yyyy-mm-dd)
Sun Life Assurance Company of Canada (Sun Life), a member of the Sun Life Financial group of companies, is committed to keeping your
information confidential.
Clear
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