SSQ Insurance Company Inc (SSQ )- Online Application

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Proposed Insured

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Sex_Quote

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Product Code

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Term Coverage

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Coverage Amount

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term, Permanent, I am not sure

Term

Permanent

I’m not sure

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Monthly Premium

Title*

Mr.

Mrs.

Ms.

First Name*

Last Name*

Name at birth (if different)

Date of birth*

Year

Month

Day

Age*

Sex*

Male

Female

Sex*

Male

Female

Place of birth (country and city)*

If you were born outside of Canada, complete the information below:

Legal status in Canada:*

Canadian citizen

Permanent resident (holds a permanent resident card)

Work permit (attach a copy of the work permit and a letter from Citizenship and Immigration Canada confirming the permanent residence request)

Refugee

Other

Please send a copy of letter from Citizenship and Immigration Canada confirming the permanent residence to [email protected]

If you were born outside of Canada, complete the information below:

Arrival date*

Year

Month

Day

Residential Address

Civic number and street name*

Apt.

City*

Province*

Postal code*

Phone Number*

Email Address*

Employment details

Profession/Occupation and years of service (current employer) – provide details*

Tasks involved in occupation*

Nature of employer’s business*

Gross annual income*

Net worth*

Other income

Specify source*

Employer’s name*

Civic number and street name*

Suite number

City*

Province*

Postal code*

Telephone (office)

Policyowner

The policyowner is:*

Insured

Other

First and last names or full legal name of company or other entity*

Relationship to insured*

Business number (if applicable)

Address*

Telephone*

Principal business or detailed occupation and field of activity (if retired, indicate the last profession and field of activity)*

Date of birth*

Year

Month

Day

Place of birth*

Age*

Sex*

Male

Female

Upon the death of a policyowner, the rights and interests of such deceased policyowner in the policy shall be transferred to the contingent/successor policyowner designated in this section.

First and last name of contingent / successor policyowner*

Relationship to insured*

Date of birth*

Year

Month

Day

Tax Information (Policyowner)

I am a tax resident of Canada (policyowner).

I am a tax resident in a jurisdiction other than Canada or the United States (policyowner).

Identity Verification

Name of the insured (as appearing on the document)*

Document Type:*

Driver’s license

Passport

Citizenship card with photo

Other photo identification document admissible by law

Please specify:

Document number*

Jurisdiction*

Document expiration date*

Year

Month

Day

SIN*

SIN

* When the insured and the policyowner are the same person, the Social Insurance Number (SIN) is required for tax purposes (applicable for whole life and universal life insurance products)

Name of the policyowner (as appearing on the document)*

Is the policyowner a Canadian citizen or a permanent resident (holds a permanent resident card)?

Yes

Document Type:*

Driver’s license

Passport

Citizenship card with photo

Other photo identification document admissible by Law

Please specify:*

Document number*

Jurisdiction*

Document expiration date*

Year

Month

Day

SIN*

SIN

Third party determination

In accordance with the Proceeds of Crime (Money Laundering) and Terrorist Financing Act and its regulations, the financial security advisor/representative must make reasonable efforts to determine, with regard to the present application, if the policyowner(s) is (are) acting on behalf of a third party (individual, company or other type of entity). When you must determine whether a “third party” is involved, it is not about who “owns” the money, but rather about who gives instructions to deal with the money. If the individual in front of you is acting on someone else’s instructions, that someone else is the third party. For the purposes of third party determination, employees acting on behalf of their employers are considered to be acting on behalf of a third party. When the premium payer is a different person or entity than the policyowner(s), the payer is considered a third party and the section below must be completed.

Is (are) the policyowner(s) acting on behalf of a third party (individual, company or other type of entity) or is there a third party to this contract?

Yes

It is impossible to determine

It is impossible to determine whether the policyowner(s) is (are) acting on behalf of a third party, but I have reasonable grounds to believe that he/she (they) is (are)

Is the person or entity paying the premiums/amounts in the insurance contract different from the policyowner(s)?

Yes

Complete the "Third party identification" section below

Third party identification

Name of the third party

Date

Year

Month

Day

Full permanent address of the third party

Principal business or detailed occupation and field of activity (if retired, indicate the last profession)

Relationship between the third party and the policyowner(s)

If the third party is a corporation or other type of entity:

Business number

Place of issuance of its certificate of constitution

If you cannot obtain the above-mentioned information on the third party, please provide the reasons in the space below:

If you cannot determine if the policyowner is acting on behalf of a third party, but have reasonable grounds to suspect that he is, please provide the reasons in the space below:

Beneficiary(ies) for life insurance

How many beneficiaries do you have?*

* Total % share must equal 100% for Primary and 100% for Contingent Beneficiaries.

Beneficiary(ies)

First and last names of beneficiary 1*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

First and last names of beneficiary 2*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

First and last names of beneficiary 3*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

First and last names of beneficiary 4*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

* Total % share must equal 100% for Primary Beneficiaries.

How many contingent beneficiaries do you have?*

Contingent beneficiary(ies) for life insurance

Contingent beneficiary 1*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

Contingent beneficiary 2*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

Contingent beneficiary 3*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

Contingent beneficiary 4*

Share*

Please enter a number from 0 to 100.

Relationship to insured (in Quebec, relationship to policyowner)*

Common-law spouse

Married/Civil union spouse

Other

Please specify:*

Designation*

Revocable

Irrevocable

* Total % share must equal 100% for Contingent Beneficiaries.

Insurance products and benefits

Permanent life insurance

Whole Life 20

Individual

Face Amount

Whole life 100

Individual

Face Amount

Term 100

Individual

Face Amount

Term life insurance

Specify coverage and face amount for each insured.

Term Plus 10

Individual – level

Individual – decreasing

Face Amount

Term Plus 15

Individual – level

Individual – decreasing

Face Amount

Term Plus 20

Individual – level

Individual – decreasing

Face Amount

Term Plus 25

Individual – level

Individual – decreasing

Face Amount

Term Plus 30

Individual – level

Individual – decreasing

Face Amount

Term Plus 35

Individual – level

Individual – decreasing

Face Amount

Term Plus 40

Individual – level

Individual – decreasing

Face Amount

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Total Face Amount

Universal life insurance

Type of Coverage

Individual

Face Amount

Cost of insurance type

Yearly Renewable Term (YRT)

T100

Other

Please Specify

Death benefit option*

Level death benefit (only available for the YRT cost of insurance type)

Increasing death benefit

Waiver of Premium*

Yes

Duration*

4 months

6 months

Type*

Waiver of minimum premium

Waiver of billing premium (up to the maximum premium)

Amount*

Waiver of Premium for the policyowner(s) – (if the policyowner is not one of the insureds)

Name(s) of the policyowner(s):

Face amount adjustment (tax exemption)

Option 1: No Increase

Option 2: Exempt Test Increase

Option 3: Increase and Decrease

Option 4: Maximizer

No face amount increase (transfer of the excess funds to the transitory deposit account).

Face amount increase (maximum 8%) and, if necessary, transfer of the excess funds to the transitory deposit account.

The Maximizer option is only available for the YRT cost of insurance type.

Universal life insurance (continued)

Maximizer option

- Do not forget to specify durations and face amount.
- In the absence of details regarding the durations and minimum face amount, the default values are as follows: The beginning of duration will correspond to 6 years from the issue date, the end of the duration will correspond to 100 years less than the insured’s age at issue and the minimum face amount will correspond to face amount of the policy.

Optimization of exemption test*

Beginning of the duration

End of the duration

Minimum face amount

Number of years*

Please enter a number greater than or equal to 6.

Number of years*

Amount*

Please enter a number greater than or equal to 25000.

Investment options and percentage split

- Please indicate your investment choices and percentage split below.
- The total percentage split must equal 100% (minimum 10% per account).
- In case no investment account is chosen, premiums and deposits are credited in the daily interest account.
- For two accounts or more, if no split percentage is specified, premiums and deposits are equally divided between the accounts.

In order to help you choose an appropriate investment strategy, it is necessary to assess your risk tolerance and the amount of return you hope to achieve, while taking into account your time horizon. Each investor’s target asset allocation mix is determined according to their situation, needs and constraints. With these factors in mind, it is necessary that your financial security advisor / representative establishes your investor profile with you in order for him/her to advise you accordingly.

Managed accounts

Conservative Strategy

Please enter a number from 0 to 100.

Balanced Strategy

Please enter a number from 0 to 100.

Growth Strategy

Please enter a number from 0 to 100.

Aggressive Strategy

Please enter a number from 0 to 100.

CI Cambridge Canadian Asset Allocation

Please enter a number from 0 to 100.

CI Signature Global Income and Growth

Please enter a number from 0 to 100.

Guardian Conservative Monthly Income

Please enter a number from 0 to 100.

Guardian Monthly Income

Please enter a number from 0 to 100.

PIMCO Bond

Please enter a number from 0 to 100.

PIMCO Global Bond

Please enter a number from 0 to 100.

Triasima Canadian Equity

Please enter a number from 0 to 100.

Guardian Canadian Dividend Equity

Please enter a number from 0 to 100.

Hillsdale US Equity

Please enter a number from 0 to 100.

Hexavest All-Country Global Equity

Please enter a number from 0 to 100.

Fiera Capital Global Equity

Please enter a number from 0 to 100.

TD Global Dividend Equity

Please enter a number from 0 to 100.

C Worldwide International Equity

Please enter a number from 0 to 100.

Lazard Global Infrastructure

Please enter a number from 0 to 100.

Morgan Stanley Global Real Estate

Please enter a number from 0 to 100.

Fisher Emerging Markets Equity

Please enter a number from 0 to 100.

Interest accounts

Daily interest account

Please enter a number from 0 to 100.

1-year guaranteed interest account

Please enter a number from 0 to 100.

3-year guaranteed interest account

Please enter a number from 0 to 100.

5-year guaranteed interest account

Please enter a number from 0 to 100.

10-year guaranteed interest account

Please enter a number from 0 to 100.

Indexed accounts

Canadian Money Market (3-month Treasury Bill)

Please enter a number from 0 to 100.

Canadian Bonds (FTSE Canada Universe Bond)

Please enter a number from 0 to 100.

Canadian Equity (S&P/TSX)

Please enter a number from 0 to 100.

US Equity (S&P 500)

Please enter a number from 0 to 100.

US Equity, Technology (MSCI US IM Information Technology 25/50)

Please enter a number from 0 to 100.

Small Cap US Equity (S&P SmallCap 600)

Please enter a number from 0 to 100.

International Equity (MSCI EAFE)

Please enter a number from 0 to 100.

Global Equity (MSCI World Ex Canada)

Please enter a number from 0 to 100.

Emerging Market Equity (MSCI Emerging Markets)

Please enter a number from 0 to 100.

Other accounts

Name

Percentage

Please enter a number from 0 to 100.

Name

Percentage

Please enter a number from 0 to 100.

Name

Percentage

Please enter a number from 0 to 100.

Name

Percentage

Please enter a number from 0 to 100.

Insurance in force

- If this application replaces any insurance in force, the prior notice of replacement form(s) must be completed and submitted, in accordance with the applicable terms of the concerned provinces, with the application or at the latest in the five (5) following working days (three (3) working days outside Quebec). A notice of replacement form is not required for the replacement of critical illness insurance, except in Quebec.

- If the insurance being replaced is a creditor’s group insurance offered by a bank, credit union or other lender, a notice of replacement form is not required.

1. Do you have existing individual insurance?*

Yes

How many?*

Company name 1*

Amount*

Type (Life, Disability, Critical Illness)*

Year*

Will this application replace in force insurance?*

Yes

Purpose of insurance*

Personal

Business

Company name 2*

Amount*

Type (Life, Disability, Critical Illness)*

Year*

Will this application replace in force insurance?*

Yes

Purpose of insurance*

Personal

Business

Company name 3*

Amount*

Type (Life, Disability, Critical Illness)*

Year*

Will this application replace in force insurance?*

Yes

Purpose of insurance*

Personal

Business

2. Do you have any other applications that are pending or that have been submitted to other companies in the last six (6) months?*

Yes

Indicate name of company, the total amount of insurance that will be put into force and the type of insurance (life, critical illness or disability).*

3. Have you ever had an application or reinstatement for life, disability or critical illness insurance declined, rated, modified or postponed?*

Yes

Indicate date and reasons.*

Purpose of insurance

Personal Insurance

Income / Loan protection

Estate conservation

Charitable donations

Temporary insurance agreement questions

- When questions 1 to 6 are answered “No” and the first premium has been received and is cashable on the date when the proposed insured(s) sign(s) the application, you are automatically eligible for temporary insurance.
- The temporary insurance agreement is not available for critical illness products and additional benefits.
- If the temporary insurance agreement is not applicable, any payment cashed upon receipt of this application will be applied towards the coming into effect of the insurance contract.

1. Have you ever had an application or reinstatement for life, disability or critical illness insurance declined, rated, postponed or otherwise modified?*

Yes

2. Have you ever suffered from any cardiovascular condition such as heart murmur, chest pain, palpitations, heart attack, peripheral vascular disease, cancer, AIDS or any other abnormality of the immune system?*

Yes

3. In the last three (3) months, have you been admitted to a medical facility, learned that you will be or that you are to undergo a medical procedure or evaluation for any reason other than for dental care, pregnancy or caesarean section?*

Yes

4. Have you ever been treated or have you been advised to undergo treatment for alcohol or drug abuse?*

Yes

5. In the last three (3) years, have you been found guilty of impaired driving, hazardous driving or refusing to submit to a breathalyzer test and/or has your driver’s license been suspended for any of the above reasons?*

Yes

6. Have you reached the age of 66 on the nearest birthday when the application is signed or is one of the insureds younger than 15 days old?*

Yes

Personal history

1. a) In the last two (2) years, have you participated in activities such as motor vehicle racing, scuba diving, parachuting, ultralight flying, hang gliding, mountaineering or mountain climbing, bungee jumping, out of bounds skiing (Heliski, catski, etc) or any other hazardous sports?*

Yes

Please specify activity.*

b) Do you intend to practice any of these activities in the next two (2) years?*

Yes

Please specify activity.*

2. a) In the last three (3) years, have you flown in an aircraft as a pilot, student pilot or crew member?*

Yes

Please specify*

b) Do you intend to practice aviation as a pilot, student pilot or crew member?*

Yes

Please specify*

3. a) In the last three (3) years, have you been convicted of two (2) or more driving offences and/or had your driver’s license suspended?*

Yes

Please provide dates and details*

b) In the last ten (10) years, have you been charged with or convicted of impaired driving, hazardous driving or have you refused to take a breathalyzer test and/or had your license suspended for any of these reasons?*

Yes

Please provide dates and relevant details.*

4. a) Do you consume alcohol beverages?*

Yes

Please specify type and number of drinks consumed on a weekly basis (1 drink = 1 glass of wine (5 ounces) or 1 beer (12 ounces) or 1.5 ounces of spirits).*

b) Has your level of alcohol beverages been higher in the past?*

Yes

Please specify type, number of drinks consumed on a weekly basis and date of change in habits (1 drink = 1 glass of wine (5 ounces) or 1 beer (12 ounces) or 1.5 ounces of spirits).*

c) Have you ever received or been advised to undergo treatment for alcohol abuse, or received counselling for this problem?*

Yes

Please indicate date, treatment, result and complete the Alcohol Use questionnaire.*

5. a) Do you use or have ever used drugs such as cannabis (marijuana, haschich, etc) LSD, cocaine, heroin, amphetamines (speed), anabolic steroids or other narcotics?*

Yes

Please provide the information below:

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Insured’s name

Type*

Quantity*

Frequency of use*

Used from:*

Year

Month

Day

Used to:*

Year

Month

Day

Add more info1

Add more info

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Insured’s name

Type

Quantity

Frequency of use

Used from:

Year

Month

Day

Used to:

Year

Month

Day

Add more info2

Add more info

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Insured’s name

Type

Quantity

Frequency of use

Used from:

Year

Month

Day

Used to:

Year

Month

Day

b) Have you ever received or been advised to undergo treatment for drug abuse, or received counselling for this problem?*

Yes

Please indicate date, treatment, result and complete the Drug Usage questionnaire.*

6. Have you ever been charged with or convicted of a criminal offence?*

Yes

Please provide the date, the circumstances, the charge(s) and the sentence (probation start and end date if applicable).*

7. a) In the last two (2) years, have you travelled or lived outside of Canada or the United States?*

Yes

Please indicate where, when and for how long.*

b) In the next two (2) years, do you intend to travel or live outside of Canada or the United States?*

Yes

If yes, complete the Foreign Residence and Travel questionnaire. Please contact your YAM Insurance representative for a copy.

8. Have you declared bankruptcy in the last three (3) years?*

Yes

If Q 8 is yes*

Personal bankruptcy

Professional/commercial bankruptcy

Amount*

Amount

Date filed:*

Year

Month

Day

Date of release:*

Year

Month

Day

Medical history

1. a) Height*

Height unit*

Weight*

Weight unit*

lbs

b) Have you lost weight in the last 12 months?*

Yes

How much?*

Reason(s) for weight change:*

c) Name and address of family doctor or the clinic holding your medical file:

d) Date and reason of last consultation

Results

e) Describe the symptoms that motivated this consultation

f) Tests performed

Results

g) Future tests or follow-ups recommended

h) Treatment provided and/or medication prescribed

For every “Yes” answer in question 2, indicate the disorder(s) or condition(s) and provide details. Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.

2. Have you ever been treated for, had symptoms or been diagnosed with any of the following disorders or conditions:

a) Cardiovascular system: chest pain, high blood pressure, elevated cholesterol, heart murmur, heart attack, stroke, angina, palpitations or heart rate disorder, abnormal ECG, pulmonary hypertension, peripheral vascular disease, blood clots, transient ischemic attack (TIA), cerebrovascular accident (CVA), or any other disorders of the heart or circulatory system or any other heart surgery? *

a) Cardiovascular system: chest pain, high blood pressure, elevated cholesterol, heart murmur, heart attack, stroke, angina, palpitations or heart rate disorder, abnormal ECG, pulmonary hypertension, peripheral vascular disease, blood clots, transient ischemic attack (TIA), cerebrovascular accident (CVA), or any other disorders of the heart or circulatory system or any other heart surgery?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

b) Respiratory system: asthma, chronic bronchitis, emphysema, cystic fibrosis, sleep apnea, chronic obstructive pulmonary disease (COPD), tuberculosis, coughing up blood, shortness of breath, chronic and persistent cough or any other respiratory disorders? *

b) Respiratory system: asthma, chronic bronchitis, emphysema, cystic fibrosis, sleep apnea, chronic obstructive pulmonary disease (COPD), tuberculosis, coughing up blood, shortness of breath, chronic and persistent cough or any other respiratory disorders?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

c) Digestive system: ulcers, colitis, bleedings, polyps or any other disorder of the stomach, esophagus, pancreas, liver such as hepatitis (including hepatitis carrier) or cirrhosis or intestines such as chronic diarrhea, ulcerative colitis, Crohn’s disease or intestinal hemorrhaging? *

c) Digestive system: ulcers, colitis, bleedings, polyps or any other disorder of the stomach, esophagus, pancreas, liver such as hepatitis (including hepatitis carrier) or cirrhosis or intestines such as chronic diarrhea, ulcerative colitis, Crohn’s disease or intestinal hemorrhaging?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

d) Genitourinary system: sugar, protein, blood or pus in urine, stones or other disorders of the kidneys such as renal failure, nephritis, disorder of the urinary tract, bladder, prostate or reproductive organs, sexually transmitted disease? *

d) Genitourinary system: sugar, protein, blood or pus in urine, stones or other disorders of the kidneys such as renal failure, nephritis, disorder of the urinary tract, bladder, prostate or reproductive organs, sexually transmitted disease?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

e) Breast disorder: mass, lump, cyst, other physical changes or abnormal biopsy or mammogram findings? *

e) Breast disorder: mass, lump, cyst, other physical changes or abnormal biopsy or mammogram findings?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

f) Neurological system: loss of consciousness or balance, dizziness, migraine, convulsions, epilepsy, numbness, optic neuritis, multiple sclerosis, Huntington’s chorea, amyotrophic lateral sclerosis (ALS), cerebral palsy, weakness of extremities, loss of sensation, memory loss, Alzheimer’s disease, Parkinson’s disease, motor neuron disease, paralysis, degenerative disease or any other disorder affecting the brain or spinal cord? *

f) Neurological system: loss of consciousness or balance, dizziness, migraine, convulsions, epilepsy, numbness, optic neuritis, multiple sclerosis, Huntington’s chorea, amyotrophic lateral sclerosis (ALS), cerebral palsy, weakness of extremities, loss of sensation, memory loss, Alzheimer’s disease, Parkinson’s disease, motor neuron disease, paralysis, degenerative disease or any other disorder affecting the brain or spinal cord?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

g) ENT system: eyes, ears, nose, mouth or throat disorder? *

g) ENT system: eyes, ears, nose, mouth or throat disorder?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

h) Endocrine and lymphatic system: diabetes, elevated glycemia, thyroid disorder, pituitary gland disorder, enlarged glands, unexplained infection or any form of endocrine or glandular disorder, malignant disease or any lymphatic gland disorder? *

h) Endocrine and lymphatic system: diabetes, elevated glycemia, thyroid disorder, pituitary gland disorder, enlarged glands, unexplained infection or any form of endocrine or glandular disorder, malignant disease or any lymphatic gland disorder?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

i) Immune system: acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC), HIV positive or any other disorder of the immune system, test indicating the presence of the AIDS virus or antibodies to the AIDS virus? *

i) Immune system: acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC), HIV positive or any other disorder of the immune system, test indicating the presence of the AIDS virus or antibodies to the AIDS virus?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

j) Psychological disorder: depression, anxiety, adjustment disorder, panic disorder, burn-out, bipolar disorder, chronic fatigue, insomnia, suicide attempts, suicidal thoughts, eating disorder, attention deficit with hyperactivity (ADHD), schizophrenia, intellectual deficiency, autism spectrum disorder or any other mental health disorder? *

j) Psychological disorder: depression, anxiety, adjustment disorder, panic disorder, burn-out, bipolar disorder, chronic fatigue, insomnia, suicide attempts, suicidal thoughts, eating disorder, attention deficit with hyperactivity (ADHD), schizophrenia, intellectual deficiency, autism spectrum disorder or any other mental health disorder?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

k) Other disorders: skin disorder, blood disorder such as anemia and coagulation disorder or any other disease or physical disorder not mentioned above? *

k) Other disorders: skin disorder, blood disorder such as anemia and coagulation disorder or any other disease or physical disorder not mentioned above?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

l) Cancer or tumor: cancer, leukemia, tumor, cyst, nodule, polyp, mole, mass or growth? *

l) Cancer or tumor: cancer, leukemia, tumor, cyst, nodule, polyp, mole, mass or growth?*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

m) Musculoskeletal disorder: back and neck pain or disorder, arthrosis, herniated disc, sprain, tendinitis, bursitis, chronic pain, fibromyalgia, muscular dystrophy, arthritis, amputation or any other disorder affecting bones, muscles, ligaments or joints such as shoulders, elbows, wrists, hands, hips, knees, ankles or feet? Provide details of the last five (5) years only *.

m) Musculoskeletal disorder: back and neck pain or disorder, arthrosis, herniated disc, sprain, tendinitis, bursitis, chronic pain, fibromyalgia, muscular dystrophy, arthritis, amputation or any other disorder affecting bones, muscles, ligaments or joints such as shoulders, elbows, wrists, hands, hips, knees, ankles or feet? Provide details of the last five (5) years only.*

Yes

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Question No.

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Insured's First Name

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

3. Are you taking any medication at the moment (other than those mentioned above)?*

Yes

Please indicate name, dosage and date at which the treatment began and reason for which it was prescribed.*

4. Are you aware of any symptoms, signs or discomfort for which you have not yet consulted a physician or received treatment?*

Yes

Please specify dates, diagnosis, tests or examinations, consultations, prescribed medication, treatments, results, and name of any attending physicians and medical facilities consulted.*

5. Have you been advised to undergo medical treatment, be hospitalized, undergo an operation or have any tests done, which have not yet been completed?*

Yes

6. In the last five (5) years, have you been a patient at a hospital, clinic or any other medical facility?*

Yes

Please indicate name, dates, reasons and results.*

7. In the last five (5) years, have you undergone an x-ray, electrocardiogram (rest or stress) or lab tests, biopsy, magnetic resonance imaging or any other diagnostic test?*

Yes

Please indicate dates, reasons and results.*

8. In the last five (5) years, have you been absent from work or had to stop your regular duties, received disability benefits or any other type of benefits as a result of an accident or illness?*

Yes

Please provide date, reason and duration.*

9. Do you have a mental or physical disorder that limits your daily activities?*

Yes

10. In the last five (5) years, have you consulted a chiropractor, physiotherapist, psychologist, audiologist, occupational therapist, osteopath, podiatrist, acupuncturist or any other health care professional?*

Yes

Insured's name

Health care professional

Reason/diagnosis

Date of first treatment

Year

Month

Day

Date of last treatment

Year

Month

Day

Number of treatment per year

Date of last symptoms

Year

Month

Day

Add more infoA

Add more info

Insured's name

Health care professional

Reason/diagnosis

Date of first treatment

Year

Month

Day

Date of last treatment

Year

Month

Day

Number of treatment per year

Date of last symptoms

Year

Month

Day

Add more infoB

Add more info

Insured's name

Health care professional

Reason/diagnosis

Date of first treatment

Year

Month

Day

Date of last treatment

Year

Month

Day

Number of treatment per year

Date of last symptoms

Year

Month

Day

11. Have any members of your family, including father, mother, brother or sister had any of the following illnesses: heart disease, transient ischemic attack (TIA), cerebrovascular accident (CVA), primary pulmonary hypertension, cancer (provide type), diabetes, kidney disease, mental or neurological illness, alcoholism, Huntington’s chorea, amyotrophic lateral sclerosis (ALS), motor neuron disease, multiple sclerosis, Alzheimer’s disease, muscular dystrophy, Parkinson’s disease or any other hereditary disorder?*

Yes

Insured's name

Relationship

Illness

Age at onset

Current age

Age at death

Cause of death

Add more infoC

Add more info

Insured's name

Relationship

Illness

Age at onset

Current age

Age at death

Cause of death

Add more infoD

Add more info

Insured's name

Relationship

Illness

Age at onset

Current age

Age at death

Cause of death

Add more infoE

Add more info

Insured's name

Relationship

Illness

Age at onset

Current age

Age at death

Cause of death

12. In the last 5 years, have you used tobacco in any form, including cigarettes, cigarillos (small cigars), cigars, pipe, chewing tobacco or snuff, shisha, betel nuts, Nicorette chewing gum, electronic cigarette or any other tobacco-derivative or nicotine-containing product?*

Yes

Insured's name

Type

Daily quantity

Date of last use

Year

Month

Day

Add more infoF

Add more info

Insured's name

Type

Daily quantity

Date of last use

Year

Month

Day

Add more infoG

Add more info

Insured's name

Type

Daily quantity

Date of last use

Year

Month

Day

Add more infoH

Add more info

Insured's name

Type

Daily quantity

Date of last use*

Year

Month

Day

Add more infoI

Add more info

Insured's name

Type

Daily quantity

Date of last use

Year

Month

Day

For women only:

a) Are you presently pregnant?

Yes

Please indicate the number of weeks you are pregnant, your weight before the pregnancy.

b) Do you have or ever had any pregnancy complications (caesarean section, preeclampsia, ectopic pregnancy, other)?

Yes

Please provide details