Application for Insurance

Transcription

1 Application for Insurance Policy number Please PRINT clearly. Canadian Chiropractic Association In this application you and your refer to the person applying for insurance. We, us, our and the Company refer to Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies. 1 General information Member information Last name First name Middle initial Dr. Mr. Ms Mrs. Miss Former/maiden name (if applicable) Male Female Date of birth (dd-mm-yyyy) Province of birth Country of birth Smoker Non-smoker means that you have not used any tobacco or tobacco n-smoker cessation products within the last 12 consecutive months. Residence address (street number and name) Apartment or suite City Province Postal code Telephone (residence) Business address (street number and name) Apartment or suite City Province Postal code address Telephone (business) Telephone (cell) Fax Member ID Member Employee of member Spouse information Last name First name Middle initial Dr. Mr. Ms Mrs. Miss Former/maiden name (if applicable) Male Female Date of birth (dd-mm-yyyy) Province of birth Country of birth Smoker Non-smoker means that you have not used any tobacco or tobacco n-smoker cessation products within the last 12 consecutive months. 2 Coverage applied for Member: Minimum 40,000 Maximum 760,000 in units of 10,000 Employee: Minimum 40,000 Maximum 500,000 in units of 10,000 Spouse: Minimum 40,000 Maximum 500,000 in units of 10,000 Life insurance Beneficiary designation for Life and AD&D insurance Revocable Irrevocable Beneficiary s first name Beneficiary s last name Relationship to proposed insured Spousal Life insurance Dependent Child Life insurance units of 2,000 maximum 10,000 per child Spousal coverage cannot exceed the member s coverage amount. The applicant is automatically the beneficiary for the spousal and dependent child life coverage. Page 1 of 12

2 2 Coverage applied for (continued) Critical Illness (CI) insurance Member and Spouse: Employees and Spouse Minimum 20,000 Maximum 100,000 in units of 10,000 Spousal Critical Illness (CI) insurance * You must check revocable or irrevocable for this application to be considered complete. Where Quebec law applies, a spouse is irrevocable unless you make the designation revocable. If the beneficiary designation is revocable, the applicant can change the beneficiary at any time without the beneficiary s consent. If the beneficiary designation is irrevocable, the beneficiary s written consent is required in order for the applicant to make any change in the beneficiary or the coverage. If you choose to designate a different beneficiary for the AD&D insurance, please provide the following information on a separate sheet of paper that you must sign, date and attach to your application: name of the beneficiary relationship to you whether the designation is revocable or irrevocable Member: Minimum 40,000 Maximum 760,000 in units of 10,000 Employee and Spouse: Minimum 40,000 Maximum 500,000 in units of 10,000 Accidental Death and Dismemberment (AD&D) insurance Single Family You must have Life insurance to be eligible for AD&D insurance. The AD&D amount cannot be higher than the Life amount. Member: Minimum 500 Maximum 7,500 in units of 100 Employee: Minimum 500 Maximum 2,500 in units of 100 Long Term Disability (LTD) insurance (per month) Cost of Living Adjustment rider (for members only) Yes Elimination Period 30 days 60 days 90 days 120 days 119 days (only option for employees) 180 days If you are only applying for Prescription Drug insurance, do not complete sections 3, 4, 5 and 6. Proceed to section 7 on page 10. You must have Life, LTD or CI insurance to be eligible for Option 3. Prescription Drug insurance only Option 1 Option 2 Single Single-parent Couple Family Prescription Drugs, EHC and Vision Care insurance Option 3 Single Single-parent Couple Family Option 3 and Dental insurance Single Single-parent Couple Family Member: Minimum 500 Maximum 8,000 in units of 100 You must have LTD insurance to be eligible for OOE insurance. Office Overhead Expense (OOE) insurance (for members only) Average monthly expenses (list only your portion): Your portion in percentage: % Number of employees: Full-time Part-time Page 2 of 12 Accounting expenses Business taxes, interest on loans Depreciation, rental costs (equipment) Insurance (office contents, etc.) Professional association membership dues Rent, mortgage interest payments Salaries and benefits for employees Telephone, answering service, pager, etc. Utilities (electricity, heat, maintenance, etc.) Other normal and fixed customary expenses Total monthly office overhead expenses (amount applied for must not exceed this figure)

3 3 Insurance information Do you currently have insurance or have you concurrently applied for any sickness or accident coverage (including Disability through your employer), Office Overhead Expense, Life or Critical Illness insurance coverage provided by individual or group policies, or employment contracts/partnership agreements? Yes If yes, please provide details below. Amount of benefit Type of coverage (DI, CI, OOE, Life, EHC) Insuring company Date of issue (mm-yyyy) Benefit period Taxable Yes Yes Will any insurance be discontinued if this certificate is issued? Yes If yes, please provide details below on the insurance which will be discontinued. Company Type of coverage Amount 4 Occupational information Occupation/title The Member and Employee must complete this section. Are you self-employed? Yes If yes, are you incorporated? Name and address of business/employer Yes Nature of business Describe occupational duties Date employment started at current employer (dd-mm-yyyy) Number of years in current occupation Number of hours worked per week Number of weeks worked per year Do you have any other occupation or contemplate changing your job duties and/or hours of work? Yes If yes, please describe fully on a separate page. Page 3 of 12

4 5 Financial information Please complete this section if you are a Member and applying for Long Term Disability insurance. Have you ever declared or are you contemplating declaring bankruptcy? Yes If yes, date of discharge: Gross annual income before business expenses (A) Date of discharge (mm-yyyy) Current year-to-date Actual Previous from to last year year mm-yyyy mm-yyyy Annual total of all your business expenses (B) Net annual income before tax (A) - (B) Is any portion of your income from a salaried position? Source of unearned income Yes If yes, please provide salary Annual unearned income not dependent on your ability to work. (e.g. net investment income from securities, banks, real estate, etc.) If none, please indicate none. If you are applying for Long Term Disability insurance, financial documents are required to confirm your income. The following income documentation will be required depending on your financial reporting situation: Employee (Salaried) Self-Employed or Partnership Incorporated Most recent T4 Income Tax Return (Pages 1 to 4) Income Tax Return (Pages 1 to 4) Statement of Business or Professional income (T2125) Most recent T4 Personal Income Tax Return (Pages 1 to 4) Business Financial Statements of the Corporation I am enclosing the required documentation, or Please contact my accountant to obtain the required income documentation. Accountant s last name First name Address Telephone number Fax number Page 4 of 12

5 6 Statement of insurability 6.1 Background information Your information Height Weight m lbs. Change in weight in the last 12 months m lbs. ft. in. m cm m kg m No change m Gain m Loss m kg Reason for weight change If no attending physician, please state none. Name of physician, date and reason for last consultation with physician Diagnosis, treatment given, results, medication prescribed If the physician named above does not have the most complete records of your medical history, please provide full name and address of the physician who does have them Please complete for Spousal coverage. Your spouse s information Height Weight m lbs. Change in weight in the last 12 months m lbs. ft. in. m cm m kg m No change m Gain m Loss m kg Reason for weight change If no attending physician, please state none. Name of physician, date and reason for last consultation with physician (if none, please state none) Diagnosis, treatment given, results, medication prescribed If the physician named above does not have the most complete records of your medical history, please provide full name and address of the physician who does have them Please complete for Dependent coverage. Your dependent(s) information First name Middle initial Last name m Male m Female Date of birth (dd-mm-yyyy) Place of birth Height Weight m lbs. Change in weight in the last 12 months m lbs. ft. in. m cm m kg m No change m Gain m Loss m kg Reason for weight change First name Middle initial Last name m Male m Female Date of birth (dd-mm-yyyy) Place of birth Height Weight m lbs. Change in weight in the last 12 months m lbs. ft. in. m cm m kg m No change m Gain m Loss m kg Reason for weight change First name Middle initial Last name m Male m Female Date of birth (dd-mm-yyyy) Place of birth Height Weight m lbs. Change in weight in the last 12 months m lbs. ft. in. m cm m kg m No change m Gain m Loss m kg Reason for weight change Page 5 of 12 If you need more space, please complete on separate sheet of paper, and sign and date it.

6 6 Statement of insurability (continued) 6.2 Family history Have any of your or your spouse s immediate family members (parents, brothers, sisters) had cancer (specify type below), tumours, heart disease, stroke, high blood pressure, You Your spouse diabetes, polycystic or other kidney disease, Alzheimer s, Parkinson s, Huntington s Chorea, multiple sclerosis, or any other inherited disease? m Yes m No m Yes m No If yes, please complete the chart(s) below. Your family history Your spouse s family history Age at Current Age at Which condition onset age death (if living) (if applicable) Age at Current Age at Which condition onset age death (if living) (if applicable) Father Mother Brother(s) Sister(s) Father Mother Brother(s) Sister(s) 6.3 Medication and/or treatment information Within the last 12 months, have any of the persons to be insured taken or been advised to take prescription drugs and/or used devices You Your spouse Your children and/or medical accessories or other treatment (therapy, counselling, etc.) including unfilled prescriptions? m Yes m No m Yes m No m Yes m No If yes please complete this section. Name of person Medication and/or to be insured Condition treatment Monthly cost Strength Daily dosage Length of time Page 6 of 12

7 6 Statement of insurability (continued) 6.4 Medical information Have you, your spouse or child(ren) (if applying for coverage) ever: You Your spouse Your child(ren) a) Had chest pain, heart attack, abnormal electrocardiogram (ECG), high blood pressure, irregular pulse, heart murmur, high cholesterol or any other disease or disorder of the heart or circulatory system? m Yes m No m Yes m No m Yes m No b) Had a stroke, 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? m Yes m No m Yes m No m Yes m No c) Had diabetes; sugar, blood or protein in the urine; disease of the kidneys, urinary tract, bladder, prostate or reproductive organs including breast lumps, cysts or other breast changes; or had an abnormal mammogram? m Yes m No m Yes m No m Yes m No d) Had tumours, cancer, polyps or other growth; disorder of the skin or lymph glands; blood disorder or any other form of malignant disease; or had a biopsy? m Yes m No m Yes m No m Yes m No e) Had chronic lung or respiratory disorder; disease or disorder of the eyes, ears, nose or throat; or colitis or any other disorder of the colon, intestines, stomach or liver? m Yes m No m Yes m No m Yes m No f) Had chronic fatigue; neck or back pain; spinal disorder; bone, muscle or joint disorder; fibromyalgia or rheumatic/arthritic disease; or lupus? m Yes m No m Yes m No m Yes m No g) Had a mental or nervous disorder; depression, anxiety state or panic attacks; eating disorder; other emotional or psychiatric disorder; or been counselled for such? m Yes m No m Yes m No m Yes m No h) Tested positive for hepatitis B, hepatitis C or human immunodeficiency virus (HIV); been identified as a hepatitis B carrier or have chronic hepatitis B; been tested for, counselled for or been told you have acquired immune deficiency syndrome (AIDS) or any other immunological disorder? m Yes m No m Yes m No m Yes m No i) Had any other illness, disease, disorder, condition or injury not listed above; had any health symptoms or complaints for which a physician has not been consulted; or been advised to have further examinations or tests which have not yet been completed? m Yes m No m Yes m No m Yes m No During the past five years, have you, your spouse or child(ren) (if applying for coverage) ever done any of the following? j) Consulted a physician, chiropractor, psychologist, physiotherapist, psychiatrist, or any other health care professional, or been admitted to a hospital or similar institution? m Yes m No m Yes m No m Yes m No k) Had any symptoms or adverse findings, or were advised to have further examinations, diagnostic tests, hospitalization or surgery? m Yes m No m Yes m No m Yes m No l) Submitted to ECGs, blood tests, x-rays or any other diagnostic tests? m Yes m No m Yes m No m Yes m No m) Had any surgical operation, treatment, special diet, illness, ailment, abnormality or injury? m Yes m No m Yes m No m Yes m No n) Had any disease or physical impairment, or are currently receiving any treatment or taking any medication, over-the-counter medications, including any herbal supplements or remedies? m Yes m No m Yes m No m Yes m No o) Been advised to have any further examinations, diagnostic tests, hospitalization or surgery which has not been completed, or had any symptoms or complaints regarding your health for which a physician has not yet been consulted? m Yes m No m Yes m No m Yes m No Page 7 of 12

8 6 Statement of insurability (continued) 6.5 Additional information You a) Do you use alcoholic beverages? m Yes m No If yes, please record the number of glasses in each category. Amount Wine Beer Liquor Daily Weekly Monthly Your spouse Do you use alcoholic beverages? m Yes m No If yes, please record the number of glasses in each category. Amount Wine Beer Liquor Daily Weekly Monthly Have you, your spouse or child(ren) (if applying for coverage) ever: You Your spouse Your children b) Consumed substantially more alcohol than outlined previously? m Yes m No m Yes m No m Yes m No c) Consulted a doctor, received treatment or counselling, been charged with impaired driving or been arrested due to the influence of alcohol and/or drugs? m Yes m No m Yes m No m Yes m No d) Had a driver s licence suspended or ever been convicted for drunk or impaired driving? m Yes m No m Yes m No m Yes m No e) Had three or more driving violations in the last three years? m Yes m No m Yes m No m Yes m No f) Used sedatives, analgesics, hypnotics, tranquilizers and/or stimulants? m Yes m No m Yes m No m Yes m No g) Used marijuana, hashish, cannabis, cocaine, narcotics, hallucinogens, heroin, barbiturates, or sought or received advice or treatment for the use of drugs, prescribed or non-prescribed or obtained over-the-counter? m Yes m No m Yes m No m Yes m No h) Have you ever used tobacco or tobacco cessation products? m Yes m No m Yes m No m Yes m No If yes, please indicate the date last used. (mm-yyyy) (mm-yyyy) (mm-yyyy) i) Had Life, Critical Illness or Disability Insurance declined, postponed, rated, rescinded, cancelled or modified in any way, or ever been denied renewal or reinstatement? m Yes m No m Yes m No m Yes m No j) Made a claim or received benefits, pension, or compensation for sickness or accident? m Yes m No m Yes m No m Yes m No k) Piloted or navigated any type of aircraft or do you engage or intend to engage in hazardous or extreme activities such as skydiving, hang gliding, scuba diving, mountain climbing, automobile or motorcycle racing, etc.? m Yes m No m Yes m No m Yes m No For female applicants only l) Are you currently pregnant? m Yes m No m Yes m No m Yes m No If yes, please indicate expected due date. (mm-yyyy) (mm-yyyy) (mm-yyyy) m) Have you had any previous complications of pregnancy such as miscarriage, pre-eclampsia, caesarean section, etc.? m Yes m No m Yes m No m Yes m No Page 8 of 12

9 6 Statement of insurability (continued) Please provide details below for any yes answers under sections 6.4 and 6.5. Include the results of all physical examinations and check-ups. If you need more space, please complete on separate sheet of paper and sign and date it. Name of person Date Name and address of physician Where applicable, include all information as to the nature of illness Question to be insured (mm-yyyyy) and hospital, if any or injury, symptoms, number of attacks, duration, treatment and results Page 9 of 12

10 7 Pre-authorized debit (PAD) agreement Please complete this section if you wish to pay your premium on a monthly basis. I/We authorize The Vigilis Group, and the financial institution designated (or any other financial institution I/We may authorize at any time) to begin variable deductions as instructed for regular recurring insurance premium payment. Regular monthly payments will be debited to my/our specified account on the 1st day of each month. Premiums payments are subject to the insurance provisions outlined in the contract. The Vigilis Group requires 10 days written notice to make any alterations or changes to this PAD Agreement. Life Insurance, Critical Illness Insurance, Long Term Disability Insurance, Office Overhead Insurance, Health and Dental Insurance Policies. The re-presentment of a payment returned due to not-sufficient funds or funds not cleared can occur only once and must be within 30 days of the original debit. If the payment is returned a second time, the method of premium payment will be altered to annual, direct billing and cannot be changed until the next policy anniversary. The proportion of the annual premium calculated to the next policy anniversary becomes immediately payable. A new PAD Agreement is required to return to the PAD method of payment. IMPORTANT (Please read carefully.) I/We may revoke my/our PAD authorization at any time by providing 10 days written notice. To obtain a cancellation form, or for more information on my/our right to cancel this PAD Agreement, I/we may contact my/our financial institution, The Vigilis Group or visit I/We have waived my/our right to receive pre-notification of the amount of the PAD and agreed that I/we do not require advance notice of the amount of PAD(s) before the debit is processed. I/We have certain recourse rights if any debit does not comply with this agreement. I/We have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD Agreement. To obtain more information on my/our recourse rights, I/we may contact my/our financial institution, The Vigilis Group or visit As this coverage is group coverage but billed on an individual basis, the PAD will be set up as a personal PAD. Plan member information (Please print.) Plan member s first name Last name Signature of plan member Date (dd-mm-yyyy) Payor, account holder information (Please print.) Name (first and last name) or Full legal name of corporation, including Co., Ltd., Inc., etc. Address (street number and name) Apartment or suite City Province Postal code Please initial to confirm that you are the only signature authorized for the firm: Signature of account holder(s) Signature of account holder(s) Date (dd-mm-yyyy) Date (dd-mm-yyyy) Bank account information (Please attach a personalized void cheque.) Name of financial institution (FI) FI Transit number (branch: 5 digits institution: 3 digits) FI Account number Address of branch (street number and name) City Province Postal code The Vigilis Group, 3285 Saint-Martin Blvd. E, Suite 200, Laval, QC H7E 4T6 Fax info@vigilis.ca You may contact us, Monday through Friday 9:00 am to 5:00 pm, by calling our toll-free number Page 10 of 12

11 8 Declaration and authorization Please read and sign this section. I declare that my answers in this Application are true and complete and I understand that concealment, misrepresentation and false declaration concerning this Application will cause the insurance to be void. I hereby certify that I have read the Medical Information Bureau (MIB) notice and having read the contents, I have, by the signature(s) below, authorized the MIB to give to Sun Life Assurance Company of Canada, or its reinsurers, any information it may have. I authorize Sun Life Assurance Company of Canada, the plan administrator (The Vigilis Group) and their agents and service providers including health professionals, institutions, the MIB, investigative agencies, insurers and reinsurers including the plan administrator to use and exchange relevant information about me in connection with this application, for the purposes of underwriting, administration and adjudicating claims under this insurance coverage. A photocopy or electronic version of this authorization is as valid as the original. Signature of applicant Signature of spouse Location signed (city) Location signed (province) Date (dd-mm-yyyy) 9 Authorization to furnish information Please read and sign this section. This portion may be provided to service intermediaries in order to obtain information. I authorize Sun Life Assurance Company of Canada, and its agents and service providers to use and exchange information needed for underwriting, administration and adjudicating claims under this insurance coverage with any person or organization who has relevant information about me including health professionals, institutions, the MIB, investigative agencies, insurers, and reinsurers. A photocopy or electronic version of this authorization is as valid as the original, and shall remain in effect for the duration of my insurance coverage. Your signature Your spouse s signature Location signed (city) Location signed (province) Date (dd-mm-yyyy) Please return your completed application to: The Vigilis Group 3285 Saint-Martin Blvd. E, Suite 200 Laval, QC H7E 4T6 Page 11 of 12

12 10 Medical Information Bureau notice In the course of underwriting your application, Sun Life Assurance Company of Canada may disclose information about you to its reinsurers. Sun Life Assurance Company of Canada and its reinsurers may also release information in their files to other life and health insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted. 11 Respecting your privacy Sun Life Assurance Company of Canada or its reinsurers may also submit a brief report of their findings to the Medical Information Bureau (MIB), a non-profit membership organization of life and health insurance companies, which operates an information exchange on behalf of its members. If the person named in this application also applies for insurance coverage or submits a claim with another life or health insurance company that is an MIB member, MIB will, on request, supply that insurance company with the information on its files. You may ask to see your personal information on file with MIB and correct anything that is inaccurate or incomplete. You may write to the MIB at: Or call: Medical Information Bureau 330 University Avenue Toronto, Ontario M5G 1R7 At Sun Life Financial, protecting your privacy is a priority. We maintain a confidential file in our offices containing personal information about you and your contract(s) with us. Our files are kept for the purpose of providing you with investment and insurance products or services that will help you meet your lifetime financial objectives. Access to your personal information is restricted to those employees, representatives and third party service providers who are responsible for the administration, processing and servicing of your contract(s) with us, our reinsurers or any other person whom you authorize. In some instances these persons may be located outside Canada, and your personal information may be subject to the laws of those foreign jurisdictions. You are entitled to consult the information contained in our file and, if applicable, to have it corrected by sending a written request to us. To find out about our Privacy Policy, visit our website at or to obtain information about our privacy practices, send a written request by to privacyofficer@sunlife.com, or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5. Page 12 of 12