ELECTRONIC APPLICATION WORKSHEET

Transcription

1 PROPOSED INSURED Last & First Name: M F Last Name at Birth: Complete Address: Date of Birth: Conserve age Tel: Work Tel: Birthplace: Since When in Canada: SIN: Legal Status: Occupation: Since: Mandatory for UL Gross Income: $ Networth: $ Employer Name: Employer Address: Previous Occupation: From: To: Purpose of Insurance: Optional App At least two years work history ELECTRONIC APPLICATION WORKSHEET Trial App Contingent Owner: M F DOB: APPLICANT (If different than insured) Full Name: M F SIN: Tel: Complete Address: Date of Birth: Birthplace: Since When in Canada: Legal Status: Relationship to Insured: Occupation: MM / YYYY Mandatory for UL Gross Income: $ Insurance In force: $ Contingent Owner: DOB: M F OTHER INSURANCE Another insurance application pending? No Yes Complete section below Date: Company: Type: Optional? Total amount to be placed: $ Ever been declined or had an application modified or postponed? No Yes Complete section below Date: Company: Type: Reason: Insurance in force on insured? No (Group life and credit insurance excluded) Yes Complete section below Company: Policy #: Type: Face Amount: Issue : Cancel? Yes No Company: Policy #: Type: Face Amount: Issue : Cancel? Yes No Company: Policy #: Type: Face Amount: Issue : Cancel? Yes No BENEFICIARY Beneficiary 1: Relationship: Beneficiary 2: Revocable Relationship: Beneficiary 3: *If you are replacing an IA policy fill out the F6A/F4A Relationship: Revocable

2 Beneficiary 4: Revocable Genesis UL Accumulation Fund Beneficiary: Critical Illness Beneficiary - In event of Critical Illness: Critical Illness Beneficiary Refund of Premiums at Death: Critical Illness Beneficiary Flexible Reimbursement of Premium: Applicant OR Insured : Irrevocable BILLING Deposit by Cheque $ Deposit by PAC POD/PAC Attach check for interim insurance PAC withdrawn within 2 days of receiving E-App for interim insurance Payment on delivery, amendment to be signed No Deposit, withdraw premium at issue time Leave First Premium section blank PAC AGREEMENT Do you already pay by PAC? No (Obtain void cheque) Yes Authorization No. of PAC Withdrawal: chosen by client: Same day as existing PAC Effective date of contract RISK CLASS Ever used tobacco or tobacco products (electronic cigarettes, gum, patches, etc.)? No Yes If yes, when did you quit? For $200,000 or more of life insurance: If preferred underwriting granted: Reduce premium Increase face amount MEDICAL REQUIREMENTS Are medicals required? Yes The agent or agency must order the medical requirements (Additional requirements may be needed) Ref #: If no reference # put Company: Obtain requirements from other insurance company: PREDECLARATION (Mandatory for cases with medical requirements) Has insured sought medical attention, been diagnosed with, received treatment for or have symptoms of any diseases or disorders below? Angina/heart attack (myocardial infarction) (with or without bypass surgery/angioplasty) Cerebral vascular accident/stroke (CVA) / Transient ischemic attack (TIA) Major depression (in last 5 yrs)/ Bipolar disorder (any duration) Chronic obstructive pulmonary disease (CPOD) / Chronic bronchitis / Emphysema Diabetes; if yes, age at diagnosis Hepatitis B or C (other than carrier) Crohn s disease/ Ulcerative colitis / Colon polyp Cancer / Malign tumor (any site) Have you been hospitalized or did you undergo a surgery for any of the reasons mentioned above? No Yes If yes, date: Hospital Name & Address: Name & address of physician monitoring situation(s) above: Are you being followed for another illness that requires three or more check-ups per year? No Yes Physician s full name, address and phone number: Disability or absence from work or school for one of the above disorders within the last 6 months? No Yes DECLARATION OF INSURABILITY Declaration of Insurability required? No Yes (If yes, complete full Declaration of Insurability questions attached) * If paramedical ordered or completed within past 6 months, no need to complete Declaration of Insurability

3 SPECIAL INSTRUCTIONS / ADDITIONAL NOTES DECLARATION OF INSURABILITY IDENTITY CONFIRMATION (Complete below section only if applying for Genesis or Trend UL) INDIVIDUAL APPLICANTS Politically Exposed Foreign Person (complete only if lump sum payment of $100,000 or more): Name: Country: Positional Details: When held: Source of Funds: CORPORATE APPLICANTS OR OTHER ENTITIES Type: Corporation Partnership Trust Individual Not-For-Profit Organization Other Provide info on all persons who control, directly or indirectly, 25% or more of shares of the corporation or 25% or more of the non corporate entity: Confirm existence of corporation or other entity by reviewing one of the following: Paper Record (Attach proof - e.g. cert. of corporate status, partnership agreement) Public electronic document (Provide registration #, type of record and source: ) Confirm identity of individual conducting transaction on behalf or corporation or non-corporate entity: Name : ID Document: Document #: Place of Issue: Expiry Date: THIRD PARTY DETERMINATION Is the Applicant acting on someone else s instructions? No Yes Complete section below Instructions provided by: Corporation Partnership Trust Individual Not-For-Profit Organization Other Name: DOB: Relationship: Address: Occupation: Instructions from Corporation? No Yes Complete section below Corp Name: Business Type: Incorporation No: Place of Incorporation: Relationship to Applicant: Address: Phone: FORM 5043 (NOV/2014)

4 Application no. 22 DECLARATION OF INSURABILITY Do not complete declarations of insurability in the following cases: Industrial Alliance holds a declaration, a telephone interview or a paramedical exam during the last six months for this insured For an additional policy, requirements are generated for the total amount of insurance submitted Proposed insured Optional if paramedical examination or phone interview required Applicant with WPDis, WPD, CAD, CADE For all Yes answers, give details below specifying the name of the proposed insured in question. YES NO YES NO 1 Within the past five years, have you consulted a physician, chiropractor or other practitioner, undergone a medical examination or been treated in a hospital, clinic or other medical facility? If yes, provide details and answer Question 2. Give reason and include medical history that prompted the consultation(s) Names, addresses and phone numbers of physicians and hospitals consulted Consultation dates (frequency) 2 a) Health problems or follow-up exams (nature of the problem, date of diagnosis, last date) b) Hospitalizations (duration) c) Treatment(s) received (type and duration) d) Medication(s) (name, dosage, duration and date last taken) e) Diagnostic examination(s) Electrocardiogram(s) X-Ray(s) Blood test(s) (nature, date, results) Other (specify) f) Follow-up examination(s) recommended (nature and date) g) Disability or absence from work (cause(s), date and duration) Details: 3 Have you consulted or been treated for pain or discomfort in the back, neck or joints (frequency, date, causes)? 4 Have you tested positive for an AIDS screening test or for Hepatitis B or C? (specify) 5 Do you have any physical or mental abnormalities? (specify) Page 18

5 Application no. 22 DECLARATION OF INSURABILITY (Continued) 6 Do you have symptoms or signs for which you have not yet consulted a physician? (specify) Proposed insured Optional if paramedical examination or phone interview required Applicant with WPDis, WPD, CAD, CADE YES NO YES NO 7 Do you take medication prescribed by a physician other than those indicated in question 2 d)? (name, dosage, reason) 8 Has any family member (father, mother, brother, sister) suffered from or is any family member suffering from diabetes, heart disease, cancer or any other hereditary disease? (Give age at diagnosis, actual age if living or age at death.) 9 Have you been exposed to the AIDS virus or Hepatitis B or Hepatitis C? 10 Have you lost or gained weight by more than 10% in the last year? (If yes, specify the gain or the loss in lbs or kgs and the reason.) 11 Height and weight ft cm lbs kg 12 In the next two years, do you plan to travel or live for more than two months outside Canada or the U.S.? (If yes, complete the foreign residence section in Questionnaire Q1A.) Questions for insured of age 15 and over 13 During the past two years, have you taken part in any hazardous sports such as parachuting, scuba diving, bungee jumping, back-country skiing, heli-skiing, mountain climbing, hang-gliding, gliding, automobile, motorcycle or motocross racing, etc.? (If yes, complete the hazardous sports section in Questionnaire Q1A.) 14 Have you made or do you intend to make aerial flights other than as a passenger? (If yes, complete the aviation section in Questionnaire Q1A.) 15 Within the past five years, have you: (If one of the answers is Yes, complete the driving record in Questionnaire Q1A.) a) been convicted of five infractions or more under the Highway Traffic Act? b) had your driver s license suspended or revoked? (If yes, give reason.) c) been convicted or do you have any charges pending for driving while impaired? (If yes, give dates) 16 Within the past 10 years, have you used drugs, narcotics or steroids? (If yes, complete the drug section in Questionnaire in Q1A.) 17 Do you or have you ever used alcohol? If yes, answer the following questions: (1 unit = 1 glass of wine = 1 bottle of beer = 1 ounce of alcohol) a) Current number of units and frequency: b) If there has been a reduction of alcohol consumption, enter the number of units and frequency before the reduction: (Specify date and reason.) c) Have you ever received treatment for alcohol use? (dates and name of physician or institution) d) Have you ever been a member of a support group (such as Alcoholics Anonymous)? Page 19