Preliminary inquiry on insurability (Not an application)

Transcription

1 Preliminary inquiry on insurability (Not an application) All questions pertain to and must be answered by the proposed insured person. Note: If the proposed insured is under age 16 (18 in Quebec) the questions must be answered by the parent or legally appointed guardian. Name (first, middle, surname) Date of birth (d/m/y) Former surname (if name changed) Sex Male Female Mailing address (number and street) City Province Postal code Occupation Employer How long employed Nature of business 1 Additional information Questions 1 and 2 below must be completed if: the proposed insured is age 65 or greater the proposed policy will be for a universal or permanent life plan (including special issues), and the death benefit amount applied for will be greater than $1,000, Is the proposed policy being purchased for the purpose of: being assigned or sold to a third party replacing a policy whose ownership has been assigned or sold to a third party, or giving a third party a legal interest in the policy? Yes No Details: If yes, give details. 2. Will the money to pay for the proposed insurance policy be borrowed? Yes No If yes, what type of loan is to be issued to fund the proposed policy? Recourse Loan (lender can personally sue you to repay the loan), or Non-recourse Loan (lender can not personally sue you to repay the loan; lender must recover the loan out of the policy proceeds) 2 General information 1. Is the preliminary inquiry being submitted for: a) a medical reason? Yes No If yes, give condition: Name and address of doctor most conversant with the medical condition: b) other? Yes No If yes, complete appropriate questionnaire. 2. Height (without shoes) cm ft & in Page 1 of 5

2 2 General information (continued) 3. Weight kg lb If weight has changed more than 4.5 kg or 10 lb in the last 12 months, give details in question a) Has any application for life or disability insurance on your life ever been declined, rated or modified in any way? _ Yes No If yes, indicate when, which company and why in question 11. b) If rated or modified, was it accepted? Yes No c) Is any other application for life or disability insurance on your life now pending with any other company? _ Yes No If yes, give name of company and date in question In the last 5 years, due to an illness or injury, have you: a) applied for, or received a pension or compensation? Yes No b) been off work for a period exceeding 2 weeks? Yes No 6. a) In the last 5 years, have you been examined by a physician for, or had any indication of Acquired Immune Deficiency Syndrome (AIDS), HIV infection or any other immunological disorder? Yes No b) Have you ever been tested for exposure to the AIDS virus? Yes No 7. Are you now under investigation, observation or taking treatment or medication? Yes No 8. a) In the last 3 years, have you smoked marijuana? Yes No b) In the last 10 years, have you used cocaine, LSD or psychoactive drugs, heroin, morphine or other narcotics? Yes No 9. a) In the last 12 months, have you smoked cigarettes, cigarillos, small or large cigars, pipes, marijuana or hashish? Yes No b) In the last 12 months, have you used any other form of tobacco or nicotine product? Yes No 10. a) In the last 5 years, have you been found guilty of an alcohol-related driving offence? Yes No b) Have you ever received counselling or medical advice to reduce or discontinue your alcohol consumption? Yes No c) Have you ever been treated for alcohol use or attended a meeting of an organization such as Alcoholics Anonymous for the purpose of rehabilitation? Yes No 11. Give details for any yes answers. If more space is required, use Additional remarks page. Question Date (m/y) number Circle the applicable items. Include diagnosis, treatment and duration. Include names and addresses of all attending physicians, medical facilities and hospitals. Page 2 of 5

3 2 General information (continued) 12. Insurance in force on proposed insured: $ Date of last policy (m/y): Name of company: 13. Proposed application: Amount $ Non-smoker Smoker Plan: Attached plans: 14. a) Proposed beneficiary name: Relationship to proposed insured: b) Applicant name: Relationship to proposed insured: 3 Authorization and agreement Acknowledgement and agreement: I confirm I ve received, read and agree to the Sun Life Financial Privacy Statement for Canada. I acknowledge that no insurance will come into effect as a result of this preliminary inquiry. Declaration: I confirm: I was present when this preliminary inquiry with the Sun Life Assurance Company of Canada (company) was completed I ve reviewed all of my answers and statements recorded on this preliminary inquiry this information is full, complete and true, and may be relied upon by the company, and I agree that my personal and medical information may be shared as set out in the Sun Life Financial Privacy Statement for Canada. Authorization: I authorize: any physician, medical practitioner, medically-related facility, insurance company, investigation agencies, the Medical Information Bureau or other organization, institution or person, including the members of the Sun Life Financial group of companies, which includes this company, that have records or knowledge of me or my health, to give only that information necessary for underwriting to the company, its representatives and its reinsurers the performance of such examinations, x-rays, electrocardiograms, blood profiles and tests for HIV (AIDS) antibody or hepatitis, if needed to underwrite this preliminary inquiry, and the company to release only the necessary personal information obtained during the underwriting process of this preliminary inquiry to my personal physician, to the Medical Information Bureau and, for any infectious or communicable disease, to the Medical Officer of Health where required by law. A photocopy of this authorization is as valid as the original. Signature of proposed insured (if under age 16 (18 in Quebec), signature of parent or guardian) X Location signed (city, province) Date (d/m/y) Financial centre no. Advisor s name Advisor s no. X Sun Life Assurance Company of Canada, Page 3 of 5

4 4 Additional remarks Additional remarks regarding any answers on the previous pages. Page 4 of 5

5 Important information you should know Sun Life Financial Privacy Statement for Canada 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, or any other person whom you authorize. In some instances these persons may be located outside of 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 learn about our Privacy Policy, visit our website at or call SUN-LIFE ( ) and request that a copy of our Privacy Brochure be sent to you. Access to your information We or our reinsurers may also submit a brief report of our findings to the Medical Information Bureau (MIB), a non-profit 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. To learn about MIB, you may visit the website at call (416) or write to: Medical Information Bureau 330 University Avenue Toronto, Ontario M5G 1R7 You may ask to see your personal information on file with MIB and correct anything that is inaccurate or incomplete. About Sun Life Financial As a leading international financial services organization, we re proud to offer a diverse range of wealth accumulation and protection products and services. Tracing our roots back to 1865, Sun Life Financial has operations in key markets around the world. But most importantly, we re in business to help people achieve and maintain the peace of mind that comes from having sound financial solutions in place. If you d like more information about Sun Life Financial, please visit our website at or call SUN-LIFE ( ). This preliminary inquiry is a request to have an assessment of insurability done. No premiums should be paid with the preliminary inquiry and the company is not on the risk as a result of this preliminary inquiry. This page should be given to client Page 5 of 5