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OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH (Equitable Life of Canada)

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OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
Head Office
One Westmount Road North
P.O. Box 1603 Stn. Waterloo, Waterloo, Ontario N2J 4C7
TF 1.800.265.4556 T 519.886.5210 F 519.883. 74 03
www.equitable.ca
509(2016/08/10) Page 1 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
Please note:
• This form may be used for a Plan Member, Spousal, and/or Child Optional Life Insurance request.
• The amount applied for on this form cannot exceed the maximum stated in your Group Policy.
• Any misrepresentation or misstatement in the answers to these questions shall render any insurance issued in connection with this application voidable by
The Equitable Life Insurance Company of Canada.
• Once completed this form can be mailed to the address above, faxed to 519.883.7403, or emailed to groupmeduw@equitable.ca.
Please note: While using the internet and email is convenient, sending confidential and personal information through the internet is not secure.
Email is vulnerable to interception. Equitable cannot ensure the privacy of information sent by email.
Name of Policyholder Policy Number Division Class Certificate Number
Plan Member’s Name
(first, middle, last) Date of Birth (mm/dd/yyyy) Place of Birth (Province/State, Country)
Address (number, street and apartment) City Province
Postal Code Email Address Telephone Number
1. PLAN MEMBER OPTIONAL LIFE INSURANCE
Plan Member Information
Contact Information for Application
Amount Requested
(Enter in multiples of $10,000)
Current Amount (if any): Additional Amount Requested: Total Amount Requested:
If available under this Policy, do you want to apply for Optional Accidental Death and Dismemberment: £ Yes £ No
If Yes, the amount will be equal to your total amount of Optional Life Insurance.
Beneficiary Information
£ Designate Beneficiary for Optional Life to be the same as Group Life Insurance provided under this Policy OR If you wish to designate a different beneficiary for Optional
Life, complete the following.
Note: If no beneficiary is appointed, the proceeds shall be payable as required by provincial law.
Full Name of Primary Beneficiary (first, middle, last) Relationship to Plan Member £ Male £ Female
If the Primary Beneficiary pre-deceases me, proceeds of the policy shall be payable to the following Contingent Beneficiary:
Full Name of Contingent Beneficiary (first, middle, last) Relationship to Plan Member £ Male £ Female
Full Name of Trustee (first, middle, last) Relationship to Plan Member £ Male £ Female
If the Beneficiary is under the age of majority at the time of my death, proceeds of the policy shall be payable to the following:
For Quebec residents only: Designating your spouse as beneficiary is irrevocable unless you make the designation revocable by checking the box below. An irrevocable beneficiary designation cannot be
changed without the written consent of the irrevocable beneficiary. A revocable beneficiary designation can be changed at any time without the consent of the revocable beneficiary.
I elect to make my spouse (married or civil union) designation: q Revocable
509(2016/08/10) Page 2 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
1. PLAN MEMBER OPTIONAL LIFE INSURANCE (CONTINUED)
Plan Member Statement
Are you now actively at work on a full time basis? £ Yes £ No
If No, give details including the reason, last day worked and anticipated date of return:
£ ft/in
£ cm
Height: Weight: Weight changes in the past year? £ Yes £ No
Amount of Gain: Amount of Loss: Reason for weight changes:
Have you smoked any cigarettes or used any other tobacco or nicotine based products, or smoking cessation aids within the last 12 months? £ Yes £ No
Products: Frequency: Date Last Used:
£ lbs
£ kg
2. SPOUSAL OPTIONAL LIFE INSURANCE
Applicant Spouse Information
Spouse’s Name (first, middle, last) £ Male £ Female Date of Birth (mm/dd/yyyy) Place of Birth (Province/State, Country)
Contact Information for Application Same as above for Plan Member £ Yes £ No If Yes, proceed to Amount Requested.
Address (number, street and apartment) City Province
Postal Code Email Address Telephone Number
Amount Requested (Enter in multiples of $10,000)
Current Amount (if any): Additional Amount Requested: Total Amount Requested:
If available under this Policy, do you want to apply for Spousal Optional Accidental Death and Dismemberment: £ Yes £ No
If Yes, the amount will be equal to your total amount of Spoursal Optional Life Insurance.
Name and address of your usual medical practitioner: (If none, state last physician contact – i.e. clinic, emergency room visit)
Date last consulted: Reason: Results/Diagnosis:
Treatment: (include check-up results)
Any follow-up advised: (e.g. tests, surgery, hospitalization) £ Yes £ No (If yes, provide full details below)
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
509(2016/08/10) Page 3 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
2. SPOUSAL OPTIONAL LIFE INSURANCE (CONTINUED)
If the Primary Beneficiary pre-deceases me, proceeds of the policy shall be payable to the following Contingent Beneficiary:
If the Beneficiary is under the age of majority at the time of my death, proceeds of the policy shall be payable to the following:
For Quebec
residents only: Designating your spouse as beneficiary is irrevocable unless you make the designation revocable by checking the box below. An irrevocable beneficiary designation cannot be
changed without the written consent of the irrevocable beneficiary. A revocable beneficiary designation can be changed at any time without the consent of the revocable beneficiary.
I elect to make my spouse (married or civil union) designation:
Applicant Spouse Statement
Are you now actively at work on a full time basis? £ Yes £ No
If No, give details including the reason, last day worked and anticipated date of return:
(30 hours per week)
£ ft/in
£ cm
Height: Weight: Weight changes in the past year? £ Yes £ No
Amount of Gain: Amount of Loss: Reason for weight changes:
Have you smoked any cigarettes or used any other tobacco or nicotine based products, or smoking cessation aids within the last 12 months? £ Yes £ No
Products: Frequency: Date Last Used:
£ lbs
£ kg
Beneficiary Information Note: If no beneficiary is appointed, the proceeds shall be payable as required by provincial law.
Full Name of Primary Beneficiary (first, middle, last) Relationship to Applicant £ Male £ Female
Full Name of Contingent Beneficiary (first, middle, last) Relationship to Applicant £ Male £ Female
Full Name of Trustee (first, middle, last) Relationship to Applicant £ Male £ Female
q Revocable
Name and address of your usual medical practitioner: (If none, state last physician contact – i.e. clinic, emergency room visit)
Date last consulted: Reason: Results/Diagnosis:
Treatment: (include check-up results)
Any follow-up advised: (e.g. tests, surgery, hospitalization) £ Yes £ No (If yes, provide full details below)
3. CHILD OPTIONAL LIFE INSURANCE (IF AVAILABLE UNDER THIS POLICY)
Note: Y
ou will be the beneficiary of your child(ren)’s Optional Life insurance. If you are not living at the time of a claim, the proceeds shall be payable as required by provincial law.
Amount Requested Per Child (Enter in multiples of $5,000)
Current Amount (if any): Additional Amount Requested: Total Amount Requested:
If available under this Policy, do you want to apply for Child Optional Accidental Death and Dismemberment: £ Yes £ No
If Yes, the amount will be equal to your total amount of Child Optional Life Insurance.
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
509(2016/08/10) Page 4 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
4. STATEMENT OF HEALTH FOR PLAN MEMBER AND SPOUSAL OPTIONAL LIFE
Note: You must complete ALL questions below. For any “Yes” answers, provide all details, including diagnosis, treatment dates, duration etc., and complete names and addresses of ALL physicians
and/or medical facilities in the space provided in Section 5.
Plan Member Spouse
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
4.1 Have you: (If yes to any of these questions, provide details including current driver’s license number)
a) Been convicted of, have pending charges for, or pleaded guilty to any other driving offences (excluding parking tickets) in
the last 3 years? .............................................................................
b) Had your driver’s license been suspended or revoked in the last 3 years? .......................................
c) Been convicted of, have pending charges for, or pleaded guilty to driving under the influence of alcohol and/or drugs,
or refused to provide a breathalyzer sample in the last 10 years? ............................................
4.2 In the last 2 years have you or do you intend to:
a) Make any flights as a pilot or in any flying capacity (other than as a fare-paying passenger)? ........................
b) Engage in a hazardous sport or hobby, such as underwater diving, hang gliding or ultra-light flying, sky diving, motorized racing,
mountain climbing, etc.).
(If so, specify sport/hobby) .......................................................
4.3 Has any family member, related by blood, (whether living or deceased) ever suffered from, or is suffering from High Blood Pressure,
Heart Disease, Stroke, Cancer (specify type), Diabetes, Kidney Disease, Mental Illness, Huntington’s Chorea, Amyotrophic Lateral
Sclerosis (ALS or Lou Gehrig’s Disease), Motor Neuron Disease, Multiple Sclerosis, Alzheimer’s Disease, Parkinson’s Disease or any
other hereditary disease?
(If yes, indicate family member, age at diagnosis and condition) .....................................
4.4 Within the past 5 years, have you received disability benefits from any source or missed 5 or more consecutive days from work due
to illness or injury or had any company decline, modify, cancel or rescind any life, disability income or critical illness insurance?
(If yes, please provide full details)
....
Have you ever been treated for or had any symptoms, complaints or indication of any of the following:
(Applies to questions 4.5 to 4.16)
4.5 Heart Attack, Angina, Chest pain, Rheumatic Fever, Stroke, TIA, Elevated Blood Pressure (include most recent Blood Pressure reading
and date), Elevated Cholesterol (include most recent levels), Heart Murmur or other Heart or Blood Vessel disease or disorder?
(If yes, please provide full details) ........................................................................
4.6 Asthma, Respiratory, Sleep Apnea or other Lung disorder? (
If yes, complete part a) .....................................
a) Respiratory Disorder
Plan Member Spouse
Plan Member Spouse
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
Do you have a history of:
£ Asthma £ Recurrent Bronchitis
£ Emphysema £ Other
Date of first episode:
Date of last episode:
Frequency of episodes:
Severity of episodes: £ Mild £ Moderate £ Severe
Have you ever been hospitalized or been seen in
Emergency? £ Yes £ No
(If yes, provide details)
Have you ever undergone tests (Pulmonary Function Tests,
Chest X-rays, other)? £ Yes £ No
(If yes, provide details)
Indicate all medications used (inhalers, oral, other)
Type: (At time of flare-up)
(
Maintenance Medications)
Dosage: (At time of flare-up)
(
Maintenance Medications)
Frequency: (At time of flare-up)
(
Maintenance Medications)
Do you have a history of:
£ Asthma £ Recurrent Bronchitis
£ Emphysema £ Other
Date of first episode:
Date of last episode:
Frequency of episodes:
Severity of episodes: £ Mild £ Moderate £ Severe
Have you ever been hospitalized or been seen in
Emergency? £ Yes £ No
(If yes, provide details)
Have you ever undergone tests (Pulmonary Function Tests,
Chest X-rays, other)? £ Yes £ No
(If yes, provide details)
Indicate all medications used (inhalers, oral, other)
Type: (At time of flare-up)
(
Maintenance Medications)
Dosage: (At time of flare-up)
(
Maintenance Medications)
Frequency: (At time of flare-up)
(
Maintenance Medications)
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
4.7 Diabetes (include age at diagnosis, date and last known Hemoglobin (A1C)), Digestive System (e.g. Gastric Ulcer), Colitis, Bowel
Disorder, Liver Disorder, Hepatitis or Hepatitis carrier state, Kidney, Bladder or Prostate, Gout or Urinary disorder, Blood or
Endocrine abnormality?
Plan Member Spouse
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
509(2016/08/10) Page 5 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
4. STATEMENT OF HEALTH FOR PLAN MEMBER AND SPOUSAL OPTIONAL LIFE (CONTINUED)
4.8 Any Eye or Ear Impairment including Visual or Hearing Impairment, Dizziness, Fainting, Convulsions, Stroke, Blurred Vision,
Seizure Disorder, etc.? .............................................................................
4.9 Thyroid, or Glandular disorder, Lupus, Multiple Sclerosis, Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease), Epilepsy,
Muscle or Bone disorder? ..........................................................................
4.10 Cancer, Tumour, Cyst, Polyp, Mole, Lump or other growth, Breast disorder or abnormal Mammogram or Ultrasound?
(If yes, include pathology results, malignant or benign) ............................................................
............................................................................
4.11 Anxiety, Stress, Depression, Fatigue, Suicidal Thoughts/Attempts, Nervous Breakdown, Eating Disorder, ADD or ADHD,
or other Nervous System disorder? (
If yes, complete part a) ....................................................
a) Nervous Disorder
Plan Member
Have you ever had any indication of the following:
Depression: £ Yes £ No
Eating Disorder: £ Yes £ No
Weight Loss: £ Yes £ No
Insomnia: £ Yes £ No
Suicidal Thoughts/Attempt: £ Yes £ No
Other, e.g. anxiety, stress: £ Yes £ No
When did you first consult a doctor/therapist and
what was the diagnosis?
Name of medications, both prescription or
non-prescription, with dates, dosage and frequency:
Are your symptoms: £ Resolved £ Unchanged
£ Less Severe £ More Severe
Any time off work? £ Yes £ No
(If yes, provide details)
Describe any current symptoms:
Spouse
Have you ever had any indication of the following:
Depression: £ Yes £ No
Eating Disorder: £ Yes £ No
Weight Loss: £ Yes £ No
Insomnia: £ Yes £ No
Suicidal Thoughts/Attempt: £ Yes £ No
Other, e.g. anxiety, stress: £ Yes £ No
When did you first consult a doctor/therapist and
what was the diagnosis?
Name of medications, both prescription or
non-prescription, with dates, dosage and frequency:
Are your symptoms: £ Resolved £ Unchanged
£ Less Severe £ More Severe
Any time off work? £ Yes £ No
(If yes, provide details)
Describe any current symptoms:
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
4.12 The Skin, Muscles, Bones and Joints, e.g. Arthritis, Knee, Back, Neck, Shoulder, Elbow, Ankle, etc. pain, Paralysis, Deformity,
unusual Skin Lesions, Migraines or Headaches, or unexplained Infections? (
If yes, complete part a)
a) Pain Questionnaire
Plan Member
Diagnosis/Cause:
If yes to any of the above, provide full details in section 5.
Spouse
If yes to any of the above, provide full details in section 5.
4.13 a) Have you ever been diagnosed or had treatment for, or have had any indication of possible exposure to AIDS (Immune
Deficiency Syndrome), ARC (AIDS Related Complex), or any other immunological disorder?
Plan Member Spouse
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
509(2016/08/10) Page 6 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
4. STATEMENT OF HEALTH FOR PLAN MEMBER AND SPOUSAL OPTIONAL LIFE (CONTINUED)
.........................
.........................
b) Have you ever had a positive test result indicating exposure to the AIDS Virus (Positive HIV)? ........................
c) Within the past 5 years, have you had any indication of a sexually transmitted disease? ...........................
4.14 Do you regularly take any medication?
(If yes, specify type, dosage, when and by whom prescribed, if not previously indicated on this form) ......
4.15 Do you have any symptoms or are you aware of any problems for which you have not yet consulted a doctor or other health
practitioner, or that has not already been listed above? .....................................................
£ Headaches £ Back £ Neck
£ Arthritis £ Other Pain Disorder
Location of Pain:
Radiating to (if applicable):
Duration of Pain:
First Episode:
Most recent Episode:
How often does pain occur?
Longest duration of discomfort:
If back or necked involved, check box: £ Neck (Cervical)
£ Middle (Thoracic) £ Low (Lumbo sacral)
i) History of medications? £ Yes £ No
ii) History of treatment
(i.e. physiotherapy, massage)? £ Yes £ No
iii) Have you been advised to undergo
any tests, investigations or surgery? £ Yes £ No
iv) Have you ever been hospitalized,
unable to work or restricted in
any way? £ Yes £ No
v) Do you have associated
symptoms or signs? £ Yes £ No
£ Headaches £ Back £ Neck
£ Arthritis £ Other Pain Disorder
Location of Pain:
Radiating to (if applicable):
Duration of Pain:
First Episode:
Most recent Episode:
How often does pain occur?
Longest duration of discomfort:
If back or necked involved, check box: £ Neck (Cervical)
£ Middle (Thoracic) £ Low (Lumbo sacral)
Diagnosis/Cause:
i) History of medications? £ Yes £ No
ii) History of treatment
(i.e. physiotherapy, massage)? £ Yes £ No
iii) Have you been advised to undergo
any tests, investigations or surgery? £ Yes £ No
iv) Have you ever been hospitalized,
unable to work or restricted in
any way? £ Yes £ No
v) Do you have associated
symptoms or signs? £ Yes £ No
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
4.16 a) Do you drink alcoholic beverages and/or use marijuana, cocaine or any illegal or addictive drugs?
b) Have you ever received advice or treatment pertaining to your use of alcohol?
c) Have you ever received advice, treatment or counselling pertaining to your use of marijuana, cocaine or any illegal
or addictive drugs?
If yes to a), b), or c), complete part d).
d) Alcohol and Drug Use
Give details regarding “Yes” answers: (“Type” refers to alcohol and/or drugs)
Plan Member
Use at
present
Previous 1-2 years
Spouse
Plan Member Spouse
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
509(2016/08/10) Page 7 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
4. STATEMENT OF HEALTH FOR PLAN MEMBER AND SPOUSAL OPTIONAL LIFE (CONTINUED)
.....................
..................................
...........................................................................
i) Alcohol .............................................
ii) Cocaine (includes Crack) .................................
iii) Marijuana and/or Hashish. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
iv) Amphetamines (Ecstasy, etc.) .............................
v) Barbiturates type: ..............
vi) Heroin, Morphine, Demerol, Methadone ......................
vii) Hallucinogens (LSD) ....................................
viii) Pain Killers/Narcotics ...................................
ix) Other: ..............
Plan Member Spouse
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
£ Yes £ No £ Yes £ No
Type: Daily Amount:
Type: Weekly Amount:
Type: Monthly Amount:
Type: Daily Amount:
Type: Weekly Amount:
Type: Monthly Amount:
Use at present
Type: Daily Amount:
Type: Weekly Amount:
Type: Monthly Amount:
Previous 1-2 years
Type: Daily Amount:
Type: Weekly Amount:
Type: Monthly Amount:
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
509(2016/08/10) Page 8 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
5. STATEMENT OF HEALTH ADDITIONAL DETAILS
If you answered “Yes” to any of the above questions in Section 4, provide full details here. If more space is needed, you can attach another page to this application.
Question # Applicant Details
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
£ Plan Member £ Spouse
q Plan Member q Spouse
£ Plan Member £ Spouse
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
509(2016/08/10) Page 9 of 9
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
6. AUTHORIZATION
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.
Signed at
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 privacy@mib.com 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)
this of 20 .
OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH
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OPTIONAL LIFE INSURANCE APPLICATION AND STATEMENT OF HEALTH (Equitable Life of Canada)

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