Evidence Of Insurability Form - Head Office Plans Page 3
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4COMPLETE ALL QUESTIONS BELOW on behalf of ALL applicants. Provide full details to ALL YES QUESTIONS.
5 Medical questions for
If you require more room for YES answers please attach a
proposed insured
Plan member
Spouse
Children
separate sheet (signed and dated).
1. During the past 12 months have you
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No
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No
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No
(a) flown as a pilot, student pilot or crew member or have any intention of doing so?
(b) engaged in racing, underwater diving, parachuting or any other hazardous sport or have any
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No
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intention of doing so?
2. Have you
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(a) ever applied for or received benefits, compensation or pension because of sickness or injury?
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No
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(b) ever had an application for life or health insurance declined, postponed, or modified in any way?
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(c) been absent from work for medical reasons during the last 5 years?
(d) currently received any treatment/medications?
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(e) any condition which might require medical consultation, hospitalization or future surgical or
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psychiatric treatment?
(f) any family history of any inherited or familial disease (e.g. Huntington's Chorea, diabetes, heart
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or kidney disease)?
3. Have you ever consulted a physician, ever been treated for, or had any known identification of
(a) chest pain, blood vessel disease, heart disorder, or heart attack or stroke?
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(b) high blood pressure?
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(c) allergies or skin disorders, including growths, cysts or tumours?
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(d) glandular disorders, including thyroid disorders and diabetes?
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(e) epilepsy, neurological disorder (e.g. Multiple Sclerosis, Parkinsons)?
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(f) nervous or mental disorder or an emotional condition such as anxiety or depression?
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(g) excessive use of alcohol or drugs?
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(h) lung disorders?
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(i) bowel, stomach or liver disorders?
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(j) cancer?
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(k) disorder of the kidney, urine or genital organs?
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(l) arthritis, rheumatism or fibromyalgia?
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(m) disorders of the muscles or bones including the back, spine or joints?
(n) immune deficiency disorder including AIDS or AIDS-related complex (ARC) or any
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generalized enlargement of the lymph glands or any test results indicating possible
exposure to the AIDS (e.g. HTLV-III, LAV) virus?
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(o) anemia, or other blood disorders?
4. Have you ever had any physical impairment, condition, disease or disorder or chronic symptoms
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including Chronic Fatigue Syndrome or chronic pain not covered above?
Please provide details below, if you have answered "Yes" to ANY questions.
If more space is needed, use another form or sheet of paper (both must be signed and dated).
Question
Name of person
Details or
Date and
Medication/treatment and results
Names and addresses of
number
(first & middle initial)
name of condition
duration
(recovery or remaining effects)
physicians and hospitals
Page 3 of 4
GL0004E (05/2007)
The Manufacturers Life Insurance Company
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