Please PRINT clearly.
Policy number 50177
Canadian Chiropractic Association
In this application
you
and
your
refer to the person applying for insurance.
We
,
us
, our and
the Company
refer to Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies.
Application for Insurance
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General information
Life insurance
Amount of insurance applied for at this time
$
Beneficiary designation for Life and AD&D insurance Revocable Irrevocable Beneficiary’s first name Beneficiary’s last name Relationship to proposed insuredSpousal Life insurance
Dependent Child Life insurance
Amount of insurance applied for at this time
$
Amount of insurance applied for at this time
$
units of $2,000
maximum $ 10,000 per child Spousal coverage cannot exceed the member’s coverage amount. The applicant is automatically the beneficiary for the spousal and dependent child life coverage.
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Coverage applied for
Member:
Minimum – $40,000 Maximum – $760,000 in units of $10,000 Employee:
Minimum – $40,000 Maximum – $500,000 in units of $10,000
Spouse:
Minimum – $40,000 Maximum – $500,000 in units of $10,000
Member information
Last name First name Middle initial Dr. Mr. Ms
Mrs. Miss
Former/maiden name (if applicable) Male
Female
Date of birth (dd-mm-yyyy)
– –
Province of birth Country of birth Smoker Non-smoker means that you have not used any tobacco or tobacco Non-smoker cessation products within the last 12 consecutive months.
Residence address (street number and name) Apartment or suite
City Province Postal code Telephone (residence)
– –
Business address (street number and name) Apartment or suite CityProvince Postal code Email address
Telephone (business)
– –
Telephone (cell)
– –
Fax
– –
Member ID Member
Employee of member
Spouse information
Last name First name Middle initial Dr. Mr. Ms
Mrs. Miss
Former/maiden name (if applicable) Male
Female
Date of birth (dd-mm-yyyy)
– –
Province of birth Country of birth Smoker Non-smoker means that you have not used any tobacco or tobacco Non-smoker cessation products within the last 12 consecutive months.
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Coverage applied for
(continued)You must have Life, LTD or CI insurance to be eligible for Option 3.
If you are only applying for Prescription Drug insurance, do not complete sections 3, 4, 5 and 6. Proceed to section 7 on page 10. Member:
Minimum – $500 Maximum – $7,500 in units of $100 Employee: Minimum – $500 Maximum – $2,500 in units of $100 Member:
Minimum – $40,000 Maximum – $760,000 in units of $10,000 Employee and Spouse: Minimum – $40,000 Maximum – $500,000 in units of $10,000
Critical Illness (CI) insurance
Spousal Critical Illness (CI) insurance
Amount of insurance applied for at this time$
Amount of insurance applied for at this time
$
* You must check revocable or irrevocable for this application to be considered complete. Where Quebec law applies, a spouse is irrevocable unless you make the designation revocable. If the beneficiary designation is revocable, the applicant can change the beneficiary at any time without the beneficiary’s consent. If the beneficiary designation is irrevocable, the beneficiary’s written consent is required in order for the applicant to make any change in the beneficiary or the coverage. If you choose to designate a different beneficiary for the AD&D insurance, please provide the following information on a separate sheet of paper that you must sign, date and attach to your application:
name of the beneficiary relationship to you
whether the designation is revocable or irrevocable
Accidental Death and Dismemberment (AD&D) insurance
Single FamilyAmount of insurance applied for at this time
$
You must have Life insurance to be eligible for AD&D insurance. The AD&D amount cannot be higher than the Life amount.
Long Term Disability (LTD) insurance
Amount of insurance applied for at this time (per month)
$
Elimination Period 30 days 60 days 90 days 120 days
119 days (only option for employees) 180 days Cost of Living Adjustment rider (for members only)
Yes No
Prescription Drug insurance only
Option 1
Option 2
Single Single-parent Couple Family
Prescription Drugs, EHC and Vision Care insurance
Option 3
Single Single-parent Couple FamilyOption 3 and Dental insurance
Single Single-parent Couple FamilyOffice Overhead Expense (OOE) insurance (for members only)
Amount of insurance applied for at this time$
Average monthly expenses (list only your portion):
Your portion in percentage: ______________ % Number of employees: ______________ Full-time
______________ Part-time
Accounting expenses
$
________________________Business taxes, interest on loans
$
________________________Depreciation, rental costs (equipment)
$
________________________Insurance (office contents, etc.)
$
________________________Professional association membership dues
$
________________________Member and Spouse: Employees and Spouse Minimum – $20,000 Maximum – $100,000 in units of $10,000
Member: Minimum – $500 Maximum – $8,000 in units of $100 You must have LTD insurance to be eligible for OOE insurance.
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Insurance information
Do you currently have insurance or have you concurrently applied for any sickness or accident coverage (including Disability through your employer), Office Overhead Expense, Life or Critical Illness insurance coverage provided by individual or group policies, or employment contracts/partnership agreements?
Yes If yes, please provide details below. No
Amount of
benefit Type of coverage (DI, CI, OOE, Life, EHC) Insuring company Date of issue (mm-yyyy) Benefit period Taxable
$
Yes No$
Yes NoWill any insurance be discontinued if this certificate is issued?
Yes If yes, please provide details below on the insurance which will be discontinued. No
Company Type of coverage Amount
$
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Occupational information
The Member and Employee must complete this section.
Occupation/title
Are you self-employed?
Yes If yes, are you incorporated? Yes No No
Name and address of business/employer
Nature of business Date employment started at current employer (dd-mm-yyyy)
– –
Number of years in current occupation
Describe occupational duties
Number of hours worked per week Number of weeks worked per year
Do you have any other occupation or contemplate changing your job duties and/or hours of work? Yes If yes, please describe fully on a separate page.
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Financial information
Have you ever declared or are you contemplating declaring bankruptcy? Yes No
If yes, date of discharge: Date of discharge (mm-yyyy)
–
Current year-to-date
Actual
Previous
from ___________ to ___________
last year
__________
year
__________
mm-yyyy mm-yyyy
Gross annual income before business expenses (A) Annual total of all your business expenses (B) Netannual income before tax (A) - (B)
$
$
$
$
$
$
Is any portion of your income Yes from a salaried position? No
If yes, please provide salary
$
Annual unearned income not dependent on your ability to work. (e.g. net investment income from securities, banks, real estate, etc.) If none, please indicate none.
$
Source of unearned incomeThe following income documentation will be required depending on your financial reporting situation:
Employee (Salaried) Self-Employed or Partnership Incorporated
• Most recent T4
• Income Tax Return (Pages 1 to 4)
• Income Tax Return (Pages 1 to 4) • Statement of Business or Professional
income (T2125)
• Most recent T4
• Personal Income Tax Return (Pages 1 to 4) • Business Financial Statements of the
Corporation I am enclosing the required documentation, or
Please contact my accountant to obtain the required income documentation.
Accountant’s last name First name
Address Telephone number
– –
Fax number
– –
EmailIf you are applying for Long Term Disability insurance, financial documents are required to confirm your income. Please complete this section if you are a Member and applying for Long Term Disability insurance.
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Statement of insurability
If no attending physician, please state none.
If no attending physician, please state none.
Please complete for Spousal coverage.
Please complete for Dependent coverage.
Your dependent(s) information
If you need more space, please complete on separate sheet of paper, and sign and date it.
6.1 Background information
Your information
Your spouse’s information
First name Middle initial Last name Male
Female
Date of birth (dd-mm-yyyy) Place of birth
– –
Height Weight lbs. Change in weight in the last 12 months lbs. ft. in. m cm kg No change Gain _______ Loss _______ kg Reason for weight change
First name Middle initial Last name Male
Female
Date of birth (dd-mm-yyyy) Place of birth
– –
Height Weight lbs. Change in weight in the last 12 months lbs. ft. in. m cm kg No change Gain _______ Loss _______ kg Reason for weight change
First name Middle initial Last name Male
Female
Date of birth (dd-mm-yyyy) Place of birth
– –
Height Weight lbs. Change in weight in the last 12 months lbs. ft. in. m cm kg No change Gain _______ Loss _______ kg Reason for weight change
Height Weight lbs. Change in weight in the last 12 months lbs.
ft. in. m cm kg No change Gain _______ Loss _______ kg Reason for weight change
Name of physician, date and reason for last consultation with physician Diagnosis, treatment given, results, medication prescribed
If the physician named above does not have the most complete records of your medical history, please provide full name and address of the physician who does have them
Height Weight lbs. Change in weight in the last 12 months lbs.
ft. in. m cm kg No change Gain _______ Loss _______ kg Reason for weight change
Name of physician, date and reason for last consultation with physician (if none, please state none) Diagnosis, treatment given, results, medication prescribed
If the physician named above does not have the most complete records of your medical history, please provide full name and address of the physician who does have them
6.2 Family history
6.3 Medication and/or treatment information
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Statement of insurability
(continued)Within the last 12 months, have any of the persons to be insured
taken or been advised to take prescription drugs and/or used devices You Your spouse Your children and/or medical accessories or other treatment (therapy, counselling, etc.)
including unfilled prescriptions? Yes No Yes No Yes No If yes please complete this section.
Your family history
Age at Current Age at Which condition onset age death
(if living) (if applicable) Father
Mother
Brother(s)
Sister(s)
Your spouse’s family history
Age at Current Age at Which condition onset age death
(if living) (if applicable) Father
Mother
Brother(s)
Sister(s)
Have any of your or your spouse’s immediate family members (parents, brothers, sisters) had cancer (specify type below), tumours, heart disease, stroke, high blood pressure, diabetes, polycystic or other kidney disease, Alzheimer’s, Parkinson’s, Huntington’s
Chorea, multiple sclerosis, or any other inherited disease? Yes No Yes No If yes, please complete the chart(s) below.
You Your spouse
Name of person Medication and/or
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Statement of insurability
(continued)6.4 Medical information
Have you, your spouse or child(ren) (if applying for coverage) ever: You Your spouse Your child(ren) a) Had chest pain, heart attack, abnormal electrocardiogram
(ECG), high blood pressure, irregular pulse, heart murmur, high cholesterol or any other disease or disorder of the heart or
circulatory system? Yes No Yes No Yes No b) Had a stroke, 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 c) Had diabetes; sugar, blood or protein in the urine; disease of the
kidneys, urinary tract, bladder, prostate or reproductive organs including breast lumps, cysts or other breast changes; or had an
abnormal mammogram? Yes No Yes No Yes No d) Had tumours, cancer, polyps or other growth; disorder of the skin
or lymph glands; blood disorder or any other form of malignant
disease; or had a biopsy? Yes No Yes No Yes No e) Had chronic lung or respiratory disorder; disease or disorder of
the eyes, ears, nose or throat; or colitis or any other disorder of
the colon, intestines, stomach or liver? Yes No Yes No Yes No f) Had chronic fatigue; neck or back pain; spinal disorder; bone,
muscle or joint disorder; fibromyalgia or rheumatic/arthritic
disease; or lupus? Yes No Yes No Yes No g) Had a mental or nervous disorder; depression, anxiety state or
panic attacks; eating disorder; other emotional or psychiatric
disorder; or been counselled for such? Yes No Yes No Yes No h) Tested positive for hepatitis B, hepatitis C or human
immunodeficiency virus (HIV); been identified as a hepatitis B carrier or have chronic hepatitis B; been tested for, counselled for or been told you have acquired immune deficiency syndrome
(AIDS) or any other immunological disorder? Yes No Yes No Yes No i) Had any other illness, disease, disorder, condition or injury not
listed above; had any health symptoms or complaints for which a physician has not been consulted; or been advised to have further
examinations or tests which have not yet been completed? Yes No Yes No Yes No During the past five years, have you, your spouse or child(ren)
(if applying for coverage) ever done any of the following?
j) Consulted a physician, chiropractor, psychologist, physiotherapist, psychiatrist, or any other health care professional, or been
admitted to a hospital or similar institution? Yes No Yes No Yes No k) Had any symptoms or adverse findings, or were advised to have
further examinations, diagnostic tests, hospitalization or surgery? Yes No Yes No Yes No l) Submitted to ECGs, blood tests, x-rays or any other diagnostic tests? Yes No Yes No Yes No m) Had any surgical operation, treatment, special diet, illness,
ailment, abnormality or injury? Yes No Yes No Yes No n) Had any disease or physical impairment, or are currently receiving
any treatment or taking any medication, over-the-counter
medications, including any herbal supplements or remedies? Yes No Yes No Yes No o) Been advised to have any further examinations, diagnostic tests,
hospitalization or surgery which has not been completed, or had any symptoms or complaints regarding your health for which a
Have you, your spouse or child(ren) (if applying for coverage) ever: You Your spouse Your children b) Consumed substantially more alcohol than outlined previously? Yes No Yes No Yes No c) Consulted a doctor, received treatment or counselling, been charged
with impaired driving or been arrested due to the influence of
alcohol and/or drugs? Yes No Yes No Yes No d) Had a driver’s licence suspended or ever been convicted for drunk
or impaired driving? Yes No Yes No Yes No e) Had three or more driving violations in the last three years? Yes No Yes No Yes No f) Used sedatives, analgesics, hypnotics, tranquilizers and/or
stimulants? Yes No Yes No Yes No g) Used marijuana, hashish, cannabis, cocaine, narcotics, hallucinogens,
heroin, barbiturates, or sought or received advice or treatment for the use of drugs, prescribed or non-prescribed or obtained
over-the-counter? Yes No Yes No Yes No h) Have you ever used tobacco or tobacco cessation products? Yes No Yes No Yes No If yes, please indicate the date last used. (mm-yyyy) (mm-yyyy) (mm-yyyy)
– – –
i) Had Life, Critical Illness or Disability Insurance declined, postponed, rated, rescinded, cancelled or modified in any way,
or ever been denied renewal or reinstatement? Yes No Yes No Yes No j) Made a claim or received benefits, pension, or compensation for
sickness or accident? Yes No Yes No Yes No k) Piloted or navigated any type of aircraft or do you engage or intend
to engage in hazardous or extreme activities such as skydiving, hang gliding, scuba diving, mountain climbing, automobile or motorcycle
racing, etc.? Yes No Yes No Yes No For female applicants only
l) Are you currently pregnant? Yes No Yes No Yes No If yes, please indicate expected due date. (mm-yyyy) (mm-yyyy) (mm-yyyy)
–
–
–
m) Have you had any previous complications of pregnancy
such as miscarriage, pre-eclampsia, caesarean section, etc.? Yes No Yes No Yes No
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Statement of insurability
(continued)6.5 Additional information
You
Daily
Weekly
Monthly
Amount Wine Beer Liquor
a) Do you use alcoholic beverages? Yes No If yes, please record the number of glasses in each category.
Your spouse
Do you use alcoholic beverages? Yes No If yes, please record the number of glasses in each category.
Daily
Weekly
Monthly
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Statement of insurability
(continued)Please provide details below for any yes answers under sections 6.4 and 6.5. Include the results of all physical examinations and check-ups.
If you need more space, please complete on separate sheet of paper and sign and date it.
Name of person Date Name and address of physician Where applicable, include all information as to the nature of illness Question to be insured (mm-yyyyy) and hospital, if any or injury, symptoms, number of attacks, duration, treatment and results
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
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Pre-authorized debit (PAD) agreement
I/We authorize The Vigilis Group, and the financial
institution designated (or any other financial institution
I/We may authorize at any time) to begin variable
deductions as instructed for regular recurring insurance
premium payment. Regular monthly payments will be
debited to my/our specified account on the 1st day of each
month. Premiums payments are subject to the
insurance provisions outlined in the contract. The Vigilis
Group requires 10 days written notice to make any
alterations or changes to this PAD Agreement.
I/We may revoke my/our PAD authorization at any
time by providing 10 days written notice. To obtain a
cancellation form, or for more information on my/our
right to cancel this PAD Agreement, I/we may contact
my/our financial institution, The Vigilis Group or visit
www.cdnpay.ca.
Life Insurance, Critical Illness Insurance, Long Term
Disability Insurance, Office Overhead Insurance, Health and
Dental Insurance Policies.
I/We have waived my/our right to receive pre-notification
of the amount of the PAD and agreed that I/we do not
require advance notice of the amount of PAD(s) before
the debit is processed.
The re-presentment of a payment returned due to
not-suf-ficient funds or funds not cleared can occur only once and
must be within 30 days of the original debit.
If the payment is
returned a second time
, the method of premium payment will
be altered to annual, direct billing and cannot be changed
until the next policy anniversary. The proportion of the
annual premium calculated to the next policy anniversary
becomes immediately payable. A new PAD Agreement is
required to return to the PAD method of payment.
I/We have certain recourse rights if any debit does not
comply with this agreement. I/We have the right to receive
reimbursement for any debit that is not authorized or is
not consistent with this PAD Agreement. To obtain more
information on my/our recourse rights, I/we may contact
my/our financial institution, The Vigilis Group or visit
www.cdnpay.ca.
As this coverage is group coverage but billed on an individual basis, the PAD will be set up as a personal PAD.
Plan member information
(Please print.)
Plan member’s first name Last name
Signature of plan member
X
Date (dd-mm-yyyy)
– –
Payor, account holder information
(Please print.)
Name (first and last name) or Full legal name of corporation, including Co., Ltd., Inc., etc.Address (street number and name) Apartment or suite City Province Postal code
Please initial to confirm that you are the only signature authorized for the firm: ______________ Signature of account holder(s)
X
Date (dd-mm-yyyy)
– –
Signature of account holder(s)X
Date (dd-mm-yyyy)
– –
Bank account information
(Please attach a personalized void cheque.)
Name of financial institution (FI) FI Transit number (branch: 5 digits – institution: 3 digits) FI Account number
IMPORTANT (Please read carefully.)
Please complete this section if you wish to pay your premium
on a monthly basis.
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Authorization to furnish information
I authorize Sun Life Assurance Company of Canada, and its agents and service providers to use and
exchange information needed for underwriting, administration and adjudicating claims under this
insurance coverage with any person or organization who has relevant information about me including
health professionals, institutions, the MIB, investigative agencies, insurers, and reinsurers.
A photocopy or electronic version of this authorization is as valid as the original, and shall remain in
effect for the duration of my insurance coverage.
Your signature
X
Your spouse’s signature
X
Location signed (city) Location signed (province) Date (dd-mm-yyyy)
– –
Please return your completed application to:
The Vigilis Group
3285 Saint-Martin Blvd. E,
Suite 200
Laval, QC H7E 4T6
Please read and sign this section.
This portion may be provided to service intermediaries in order to obtain information.
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Declaration and authorization
Please read and sign this
section.
I declare that my answers in this Application are true and complete and I understand that
concealment, misrepresentation and false declaration concerning this Application will cause the
insurance to be void.
I hereby certify that I have read the Medical Information Bureau (MIB) notice and having read
the contents, I have, by the signature(s) below, authorized the MIB to give to Sun Life Assurance
Company of Canada, or its reinsurers, any information it may have.
I authorize Sun Life Assurance Company of Canada, the plan administrator (The Vigilis Group) and their
agents and service providers including health professionals, institutions, the MIB, investigative agencies,
insurers and reinsurers including the plan administrator to use and exchange relevant information
about me in connection with this application, for the purposes of underwriting, administration and
adjudicating claims under this insurance coverage.
A photocopy or electronic version of this authorization is as valid as the original.
Signature of applicant
X
Signature of spouse
X
Location signed (city) Location signed (province) Date (dd-mm-yyyy)
– –
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Respecting your privacy
At Sun Life Financial, protecting your privacy is a priority. We maintain a confidential file in our offices containing personal information about you and your contract(s) with us. Our files are kept for the purpose of providing you with investment and insurance products or services that will help you meet your lifetime financial objectives. Access to your personal information is restricted to those employees, representatives and third party service providers who are responsible for the administration, processing and servicing of your contract(s) with us, our reinsurers or any other person whom you authorize. In some instances these persons may be located outside Canada, and your personal information may be subject to the laws of those foreign jurisdictions. You are entitled to consult the information contained in our file and, if applicable, to have it corrected by sending a written request to us.
To find out about our Privacy Policy, visit our website at www.sunlife.ca, or to obtain information about our privacy practices, send a written request by e-mail to [email protected], or by mail to Privacy Officer, Sun Life Financial, 225 King St. West, Toronto, ON M5V 3C5.
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Medical Information Bureau notice
In the course of underwriting your application, Sun Life Assurance Company of Canada may disclose information about you to its reinsurers. Sun Life Assurance Company of Canada and its reinsurers may also release information in their files to other life and health insurance companies to whom you may apply for life or health insurance or to whom a claim for benefits may be submitted.
Sun Life Assurance Company of Canada or its reinsurers may also submit a brief report of their findings to the Medical Information Bureau (MIB), a non-profit membership organization of life and health insurance companies, which operates an information exchange on behalf of its members. If the person named in this application also applies for insurance coverage or submits a claim with another life or health insurance company that is an MIB member, MIB will, on request, supply that insurance company with the information on its files.
You may ask to see your personal information on file with MIB and correct anything that is inaccurate or incomplete.
You may write to the MIB at: Medical Information Bureau 330 University Avenue Toronto, Ontario M5G 1R7 Or call: 416-597-0590
