Evidence Of Insurability Form - Head Office Plans Page 2
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4Please provide the following information for each dependant to be insured.
4 Dependant information
If you have more than three children, please attach separate sheet (signed and dated) and include all
personal information as requested above.
Child's name (last, first and middle initial)
Sex
Date of birth (dd/mmm/yyyy)
Height
Weight
Male
kg
__________ m
__________ cm
Female
lb
__________ ft
__________ in
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
If "No," please provide:
Dependant physician - Is name of personal physician the same as member?
Yes
No
Name of personal physician (last, first and middle initial)
Address of personal physician (number, street, suite)
Physician's phone number
(
)
City
Province
Postal code
Child's name (last, first and middle initial)
Sex
Date of birth (dd/mmm/yyyy)
Height
Weight
Male
kg
__________ m
__________ cm
Female
lb
__________ ft
__________ in
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?
Reason
Was this a gain
or a loss?
kg
lb
If "No," please provide:
Dependant physician - Is name of personal physician the same as member?
Yes
No
Name of personal physician (last, first and middle initial)
Address of personal physician (number, street, suite)
Physician's phone number
(
)
City
Province
Postal code
Child's name (last, first and middle initial)
Sex
Date of birth (dd/mmm/yyyy)
Height
Weight
kg
Male
__________ m
__________ cm
Female
lb
__________ ft
__________ in
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
If "No," please provide:
Dependant physician - Is name of personal physician the same as member?
Yes
No
Name of personal physician (last, first and middle initial)
Address of personal physician (number, street, suite)
Physician's phone number
(
)
City
Province
Postal code
Page 2 of 4
GL0004E (05/2007)
The Manufacturers Life Insurance Company
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