509(2016/08/10) Page 9 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
THE APPLICANT MEMBER AND ALL DEPENDENTS AGE 16 YEARS AND OLDER, DECLARE, AGREE AND CERTIFY THAT:
1. All the statements, information and answers provided in all sections of this Application are true, complete, accurate and correctly recorded.
2. T he personal information willingly provided by the member to the member’s employer, the independent broker/sales advisor and The Equitable Life Insurance Company of Canada (Equitable),
collected on this Application and held in their ﬁles, will be used by Equitable for the purposes of underwriting, servicing, administration, claims processing and adjudication related to this Application,
the Policy and all beneﬁts under the Policy, and any supplementary documents. The member understands and authorizes that for the above purposes the personal information on ﬁle is accessible to
and may be exchanged with, authorized employees of, and relevant third parties retained by Equitable, any industry drug pooling entity, participating reinsurer(s), other insurance companies,
investigative parties, health care providers, including, but not limited to pharmacies, physicians and dentists, and any other person or party whom the member authorizes. If applying for the member’s
spouse and/or dependents, the member conﬁrms that the member is authorized to act on their behalf and therefore this consent and authorization also applies to the collection, use and
communication of their personal information for the same purposes. The member understands that all claims made under the Policy are submitted through the member as insured plan
member. The member therefore authorizes Equitable to exchange information about these claims with the member or any person acting on the member’s behalf, including a spouse or dependent,
as deemed necessary for the purposes of conﬁrming eligibility and assessing and managing a claim.
THE APPLICANT MEMBER AND ALL DEPENDENTS AGE 16 YEARS AND OLDER:
1. Agree that the insurance being applied for in this Application or such insurance as issued by Equitable shall not take effect unless the ﬁrst premium for the insurance coverage has been paid.
2. Acknowledge receiving the Notice regarding the Medical Information Bureau and authorize Equitable to obtain information from the Medical Information Bureau;
3. Authorize Equitable to perform all tests, including, without limitation, examinations, x-rays, electrocardiograms, and blood tests as may be required to underwrite this Application. Such tests may
include tests to determine the presence of various diseases including the antibodies or virus related to Acquired Immunodeﬁciency Syndrome (AIDS). Equitable may disclose to its reinsurer(s), their
attending physician(s), health service providers, and the Medical Information Bureau, the results of all such tests and personal information necessary to fulﬁll any of the identiﬁed purposes in this
Application. I/We understand and agree that any positive results for HIV, hepatitis, or any other communicable diseases will be reported to the appropriate Public Health Authority. Their personal
information collected by the testing facility may be processed and stored by such facility in Canada and/or the U.S. and, as such, may be subject to disclosure to the Canadian and U.S. Governments
and agencies through the laws and treaties of and between Canada and the U.S.
4. Authorize the Motor Vehicle Division in any province requiring such authorization to permit Equitable or any investigative agency on behalf of Equitable, to be given a copy of all driving record
information relevant to this Application.
5. Authorize any physician, practitioner, hospital, clinic, or other medical-related facility, insurance company, the Medical Information Bureau or any other organization, institution or person, that has any
record or knowledge of the person(s) this insurance is applied for, or their health, to give full particulars of such information, including any prior medical history, to Equitable or its reinsurers.
6. Agree that this Application may be transmitted to Equitable electronically and received by Equitable as the Applicant’s original application for insurance.
7. A photostatic copy of these authorizations shall be as valid as the original.
FAILURE TO DISCLOSE EVERY FACT WITHIN THE APPLICANT MEMBER’S KNOWLEDGE AND WITHIN THE KNOWLEDGE OF THE PERSON(S) AGED 16 YEARS OR OLDER, THAT IS
MATERIAL TO THE INSURANCE BEING APPLIED FOR, OR MATERIAL TO THE INSURABILITY AND HEALTH OF ALL PERSON(S) TO BE INSURED OR, ANY MISREPRESENTATION OR
MISSTATEMENT OF ANY FACTS, STATEMENTS, INFORMATION OR ANSWERS GIVEN AND CONTAINED IN THIS APPLICATION AND ANY WRITTEN STATEMENTS GIVEN AS EVIDENCE OF
INSURABILITY SHALL RENDER ANY INSURANCE ISSUED IN CONNECTION WITH THIS APPLICATION VOIDABLE BY EQUITABLE.
Signature of Member
(Employee) Signature of Spouse of Member (when applicable)
Signature of Dependent Child(ren) (when applicable) age 16 or older
NOTICE REGARDING THE MIB, INC
Information regarding the insurability of the Person(s) to be Insured will be treated as conﬁdential. We or our reinsurer may, however, make a brief report thereon to the MIB, Inc., formerly known as Medical
Information Bureau, a non-proﬁt membership organization of life insurance companies, which operates an information exchange on behalf of its members. If the Person(s) to be Insured apply(ies) to another
MIB member company for life, critical illness or health insurance coverage, or claim for beneﬁts is submitted to such a company, MIB, upon request, will supply such company with the information it may have in
its ﬁle. As a U.S. based company, MIB complies with U.S. privacy laws. MIB protects personal information in a manner similar to Canadian privacy laws. Upon receipt of a request from you, the MIB will arrange
disclosure of any information it may have in your ﬁle. If you question the accuracy of information in MIB’s ﬁle, you may contact MIB and seek a correction. The address of MIB’s Information Ofﬁce is 330
University Avenue, Suite 501, Toronto, Ontario, M5G 1R7; telephone number (416) 597-0590, or firstname.lastname@example.org for privacy questions. We or our reinsurer(s) may also release information in our ﬁles to
other life insurance companies to whom the Proposed Life Insured may apply for life, critical illness or health insurance or to whom a claim for beneﬁts may be submitted. Information for consumers about MIB
may be obtained on its website at www.mib.com
(city) (province) (day) (month)
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OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH