Health statement

Important
• Incomplete forms will delay processing.
• Part 1 is to be completed by the plan administrator or the plan member with information provided by the plan administrator.
• Plan member to mail form directly to Sun Life Assurance Company of Canada.
Please PRINT clearly.
Please answer the following questions completely and accurately. If you’re not sure whether some information is relevant, provide it
anyway. If you do not disclose all relevant information, claims may be denied and insurance cancelled.
Clear
1 Plan administrator information (to be completed by the plan administrator or the member)
Coverage is not in effect until you receive notice of approval from Sun Life Assurance Company of Canada.
Member’s last name Member’s first name Contract number

Kane Michael 022169

Occupation Class Billing group Member ID

F 007 3196252
Current salary Hrly. Wkly. Bi-Wkly. Company name Plan administrator’s name

$ Mthly. Ann.

Company street address City Province Postal code Telephone number

Reason for application

New enrolment – effective date (dd-mm-yyyy)

Increased coverage
Late applicant (enrolled after 31 days)
Re-application (previously declined)
Annual enrolment – effective date (dd-mm-yyyy)
Benefits requested A. Existing amount of coverage B. New amount of coverage C. Total amount of coverage
(Please check off) (if applicable) requested (A + B)

Basic Life – member $ $ $

Basic Life – spouse $ $ $

Basic Life – dependent $ $ $

Optional Life – member $ $ $

Optional Life – spouse $ $ $

Optional Life – dependent $ $ $

Critical Illness – member $ $ $

Critical Illness – spouse $ $ $

Critical Illness – dependent $ $ $

Long-term disability $ $ $

Short-term disability $ $ $

Other $ $ $

Extended Health – member* New benefit Yes No

Extended Health – dependent* New benefit Yes No
Dental – member* New benefit Yes No
Dental – dependent* New benefit Yes No

* If applicable – Date of loss of comparable coverage (dd-mm-yyyy)

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 2 Member and dependent details (to be completed by the member)
2.1 General information about the member (Do not tell us about genetic testing or genetic test results.)
Member’s last name Member’s first name Date of birth (dd-mm-yyyy) Male
Kane Michael 05 02 1985 Female
Member’s street address (street number and name) Apartment or suite City Province Postal code
#1201 - 7088 Salisbury Avenue Burnaby BC V5E 0A4
Please provide all applicable contact information where you can be reached for additional information Email address
Home telephone number Day Evening Business telephone number Day Evening

Height Weight lbs. Change in weight in the last 12 months lbs. Reason for weight change
kg No change Gain Loss kg
ft. in. m cm
Date and reason for your last consultation with attending doctor (if no attending doctor, please state none)

Name of doctor, diagnosis, treatment given, results, medication prescribed (Do not tell us about genetic testing or genetic test results).

If the doctor named above does not have the most complete records of your medical history, please provide full name and address of the doctor who does have them

2.2 General information about the member’s dependents

(complete this section only if applying for dependent coverage and do not tell us about genetic tests or genetic test results)
Spouse’s last name Spouse’s first name Date of birth (dd-mm-yyyy) Male
Female
Height Weight lbs. Change in weight in the last 12 months lbs. Reason for weight change
kg No change Gain Loss kg
ft. in. m cm
Date, reason and results for your dependent’s last consultation with attending doctor (if no attending doctor, please state none)

Name of doctor, diagnosis, treatment given, results, medication prescribed (Do not tell us about genetic testing or genetic test results.)

If the doctor named above does not have the most complete records of your dependent’s medical history, please provide full name and address of the doctor who does have them

Child’s last name Child’s first name Date of birth (dd-mm-yyyy) Male Height Weight lbs.
Female ft. in. m cm kg
Child’s last name Child’s first name Date of birth (dd-mm-yyyy) Male Height Weight lbs.
Female ft. in. m cm kg
Child’s last name Child’s first name Date of birth (dd-mm-yyyy) Male Height Weight lbs.
Female ft. in. m cm kg

2.3 Family history information

Have any of your or your spouse’s immediate family members (parents, brothers, sisters) had Member Spouse
heart disease, heart attack, high blood pressure, polycystic kidney disease, familial polyposis of the
bowel, stroke, diabetes, cancer (specify type below), multiple sclerosis, Huntington’s Chorea,
Alzheimer’s, Parkinson’s, ALS (Amyotrophic Lateral Sclerosis) or any hereditary disease? Yes No Yes No
If “yes”, complete chart below.
Member’s family history (Do not tell us about genetic testing or genetic test results.)
Current age Age at death
Which condition(s) Age at onset (if living) (if applicable)
Father

Mother

Brother(s)

Sister(s)

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 2 Member and dependent details (to be completed by the member) (continued)
Spouse’s family history (Do not tell us about genetic testing or genetic test results.)
Current age Age at death
Which condition(s) Age at onset (if living) (if applicable)
Father

Mother

Brother(s)

Sister(s)
2.4 Medical information (complete this section only for person(s) applying for insurance)
Complete section(s) 2.4, 2.5 and/or 2.6, as applicable, with any additional comments to these questions.
If you answer “yes” to any questions, please provide further details on the next page. Include dates, treatment, medications and results
but do not tell us about genetic testing or test results.
Member Spouse Child(ren)
1. Have you ever:
a) Been admitted to a hospital or clinic as a patient (except for pregnancy or birth) for longer
than five consecutive days? Yes No Yes No Yes No
b) Received disability benefits for three months or longer? Yes No Yes No Yes No
c) Been declined or offered Life, Disability or Critical Illness insurance at a higher than
standard risk? (If yes, specify name of insurer, date and reason) Yes No Yes No Yes No
2. Have you used any nicotine products (tobacco, e-cigarettes, patches, etc.) within the
last 12 months? Yes No Yes No Yes No

3. Within the last 10 years, have you used cocaine, hashish, heroin, narcotics, marijuana,
LSD, hallucinogens, amphetamines, except as prescribed by a doctor, or sought or received
advice or treatment for the use of drugs (over-the-counter, prescribed or
non-prescribed)? Yes No Yes No Yes No

4. Do you consume alcoholic beverages? Yes No Yes No Yes No

a) Average number of drinks per week
b) Have you ever been advised to stop drinking, to drink less or received treatment for the
use of alcohol? Yes No Yes No Yes No
Who
(e.g. spouse, friend, doctor, etc.)

Reason Date (dd-mm-yyyy)

5. Are you presently under medical treatment by diet, medicine or other means? (provide details
including names of all medications and reason(s) why you are using them) Yes No Yes No Yes No

6. Have you ever had diabetes, impaired sugar levels or ever had sugar, blood or protein
in your urine? Yes No Yes No Yes No
What is your current treatment for diabetes? Insulin: Yes No Yes No Yes No
Oral medication: Yes No Yes No Yes No
Diet only: Yes No Yes No Yes No

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 2 Member and dependent details (to be completed by the member) (continued)
Member Spouse Child(ren)
7. Have you ever had or received treatment for, consulted a doctor or other health practitioner
for, or been diagnosed as having any one of the following:
a) Cancer, malignancy, leukemia, enlarged lymph nodes, lymph gland disorder, tumours,
polyps or other growths including moles, breast lumps or cysts, had a biopsy for any
reason or had an abnormal cancer screening test? Yes No Yes No Yes No
b) Illnesses of the heart or circulatory system, including chest pain, abnormal
electrocardiogram (ECG), irregular pulse, heart murmur? Yes No Yes No Yes No
c) Liver disorder or any type of hepatitis or blood disorders? Yes No Yes No Yes No
d) Disease or disorder of the kidneys, urinary tract, bladder, prostate or reproductive organs? Yes No Yes No Yes No
e) Chronic lung or respiratory disorder (including asthma and sleep apnea), disease or disorder
of the eyes, ears, nose or throat? Yes No Yes No Yes No
f) 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? Yes No Yes No Yes No
g) Psychiatric or psychological problems (including anxiety, depression, panic attacks, eating
disorders, any other emotional disorders) or been counselled for such? Yes No Yes No Yes No
h) Chronic fatigue syndrome, fibromyalgia, rheumatic/arthritic disease or lupus? Yes No Yes No Yes No
i) Musculoskeletal, joint or bone disorders, paralysis or numbness? Yes No Yes No Yes No
j) Back and neck problems? Yes No Yes No Yes No
k) High blood pressure? Yes No Yes No Yes No
l) High cholesterol? Yes No Yes No Yes No
m) Gastrointestinal disorder (including esophageal, stomach, colon, colitis or bowel/intestinal
disorders)? Yes No Yes No Yes No
8. Have you ever tested positive for AIDS, ARC or HIV? Yes No Yes No Yes No

9. Have you ever suffered a heart attack or myocardial infarction? Yes No Yes No Yes No

10. Have you ever had a stroke? Yes No Yes No Yes No

11. Have you ever had an organ transplant? Yes No Yes No Yes No

12. Have you ever had any other illness, disease or disorder, condition, injury, diagnostic testing or
surgical procedure not listed above? Do not take genetic testing or genetic test results into Yes No Yes No Yes No
consideration. If, for example, you have not had any other illness, disorder, condition or
surgery and you have only undergone genetic testing, then you can still answer "no".
13. Have you ever used any special medical equipment or appliances such as a walker, cane,
wheelchair, catheter, oxygen tank, pacemaker, artificial limb or hearing aid? Yes No Yes No Yes No

14. Do you require assistance of any kind to perform any daily activities, such as bathing,
continence, dressing, eating, using the toilet or transferring (for example: bed to chair)? Yes No Yes No Yes No

15. Have you ever had any health symptoms or complaints for which a doctor has not been
consulted or been advised to have further examinations or tests which have not been
completed yet? Do not take genetic testing or genetic test results into consideration. If, for Yes No Yes No Yes No
example, you have not had any other illness, disorder, condition or surgery and you have
only undergone genetic testing, then you can still answer "no".
If you answered yes to any questions in the previous section, please provide further details. Use a separate sheet of paper if you need
more space but ensure all additional sheets are signed, dated and stapled to this form.
2.5 Additional medical details – Member (do not tell us about genetic testing or genetic test results.)
Question Further details

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 2 Member and dependent details (to be completed by the member) (continued)
2.6 Additional medical details – Dependent Spouse/Children (do not tell us about genetic testing or genetic test results.)
Question Dependent name Further details

3 Declaration and authorization (please read and sign this section)

In this declaration and authorization, “I” applies to each of the member, the spouse and the child(ren) age 18 and older signing
below.
I understand I may be refused those group benefits or any benefit amounts for which proof of good health is required if, in
the opinion of Sun Life Assurance Company of Canada, I am not insurable. I certify that all the statements in this form are
true and complete and I understand that concealment, misrepresentation and false declaration concerning this Health
statement, will cause the insurance to be void.
I authorize Sun Life Assurance Company of Canada, its agents and service providers to collect, use and disclose information
needed for underwriting, administrating and adjudicating claims under this Plan with any person or organization who has
relevant information about me and/or my dependents under age 18 (if applicable), pertaining to this Health statement. This
includes any health professionals, institutions, investigative agencies, insurers and reinsurers.
If I am a spouse or dependent age 18 and older, I also authorize Sun Life Assurance Company of Canada to disclose
information about this application to the member, for the purposes of assessing this application and managing the group
benefits plan.
I agree that a photocopy of this authorization or electronic version is as valid as the original and shall continue to have effect
throughout the duration of my coverage under this group contract, unless withdrawn in writing.
Signature of member Date (dd-mm-yyyy)
X
Signature of spouse Date (dd-mm-yyyy)
X
Signature of dependent child 18 years or older Date (dd-mm-yyyy)
X
Signature of dependent child 18 years or older Date (dd-mm-yyyy)
X
Sun Life Assurance Company of Canada must receive your completed Health statement within 60 days of the date you
complete, sign and date the form, otherwise you will need to submit a new Health statement.
All information received by Sun Life Assurance Company of Canada is treated as strictly confidential and is used for the sole
purpose of determining your eligibility and administering the group plan to which you belong. Returning your forms and
medical information to us in a confidential envelope ensures that only our medical underwriters will have access to them.
Please fully complete the address.
Send the completed form to one of the following addresses in an envelope marked "Confidential" and retain a copy for your records.
Toll-free fax number: 1-877-897-5519 Toll-free fax number: 1-877-897-6605
Sun Life Assurance Company of Canada Sun Life Assurance Company of Canada
Medical Underwriting Medical Underwriting
Private and Confidential Private and Confidential
PO Box 11691 Stn CV PO Box 578 Stn Waterloo
Montreal QC H3C 3J9 Waterloo ON N2J 4B8
Toll-free number: 1-866-882-0884
Sun Life Assurance Company of Canada is a member of the Sun Life Financial group of companies.

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 Respecting your privacy
Respecting your privacy is a priority for the Sun Life Financial group of companies. We keep in confidence personal information about you
and the products and services you have with us to provide you with investment, retirement and insurance products and services to help
you meet your lifetime financial objectives. To meet these objectives, we collect, use and disclose your personal information for purposes
that include: underwriting; administration; claims adjudication; protecting against fraud, errors or misrepresentations; meeting legal,
regulatory or contractual requirements; and we may tell you about other related products and services that we believe meet your
changing needs. The only people who have access to your personal information are our employees, distribution partners such as advisors,
and third-party service providers, along with our reinsurers. We will also provide access to anyone else you authorize. Sometimes, unless
we are otherwise prohibited, these people may be in countries outside Canada, so your personal information may be subject to the laws
of those countries. You can ask for the information in our files about you and, if necessary, ask us in writing to correct it. To find out more
about our privacy practices, visit www.sunlife.ca/privacy.

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