Evidence Of Insurability Form - Head Office Plans

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Group Benefits
Evidence of Insurability - Head Office Plans
INSTRUCTIONS - Please print all answers
1.
Please consult your plan administrator for type of coverage available under your plan. Check (
) the appropriate box to indicate the type of coverage for
which you are applying.
PLAN MEMBER ONLY
PLAN MEMBER AND SPOUSE
PLAN MEMBER, SPOUSE AND DEPENDANTS
SPOUSE AND/OR DEPENDANTS
2. Please ensure that ALL SECTIONS are completed.
Section 1 - Plan sponsor information - TO BE COMPLETED FIRST BY PLAN ADMINISTRATOR.
Sections 2, 3, 4, 5, 6 and 7 - Plan member/spouse information - To be completed by plan member/spouse and submitted to Manulife Financial.
3. If required, retain a photocopy for your files.
1
Plan sponsor information
Plan contract number(s)
Division number
Plan member certificate number
Plan sponsor
Plan administrator name
Phone number
E-mail address
(
)
Plan member statement
Plan member's name (last, first and middle initial)
Occupation
2
Sex
Date of birth (dd/mmm/yyyy)
Home phone number
Business phone number
Male
Female
(
)
(
)
Plan member's address (number, street, apartment)
City
Province
Postal code
Weight
Have you smoked (cigarettes, cigars, pipe, etc.) or used tobacco
Height
kg
in any other form within the last 12 months?
__________ m
__________ cm
lb
__________ ft
__________ in
Yes
No
Have you lost or gained more than 10 lbs. during the last 12 months?
Yes
No
If "Yes", please answer the following:
What was the amount of weight change?
Was this a gain
Reason
or a loss?
kg
lb
Name of personal physician (last, first and middle initial)
Address of personal physician (number, street, suite)
Physician's phone number
(
)
City
Province
Postal code
Spousal statement
Spouse's name (last, first and middle initial)
3
Sex
Date of birth (dd/mmm/yyyy)
Home phone number
Business phone number
Male
Female
(
)
(
)
Height
Weight
Have you smoked (cigarettes, cigars, pipe, etc.) or used tobacco
kg
__________ m
__________ cm
in any other form within the last 12 months?
lb
__________ ft
__________ in
Yes
No
Have you lost or gained more than 10 lbs. during the last 12 months?
Yes
No
If "Yes", please answer the following:
What was the amount of weight change?
Was this a gain
Reason
or a loss?
kg
lb
Name of personal physician (last, first and middle initial)
Address of personal physician (number, street, suite)
Physician's phone number
(
)
City
Province
Postal code
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GL0004E (05/2007)
The Manufacturers Life Insurance Company

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