Sun Life Financial / Financière Sun Life

Member and dependent details

Please complete the following medical/lifestyle questions for yourself and your dependents. If you answer yes to any question, please provide further details including dates, treatment and medications as applicable.

Information marked with an * is required.

2.3 Medical information - Questions 1 to 7 of 30

1.	* Do you have a regular attending Doctor?

Randy Doe (member)

* Yes No

	Doctor's name:	*
	Doctor's address:	*
	Date last consulted:	* day month year
	Reason consulted:	*

Eva Christen Doe (spouse)

* Yes No

	Doctor's name:	*
	Doctor's address:	*
	Date last consulted:	* day month year
	Reason consulted:	*

Andreia Doe (child)

* Yes No

	Doctor's name:	*
	Doctor's address:	*
	Date last consulted:	* day month year
	Reason consulted:	*

2.	* Do you have a yearly check-up?

Randy Doe (member)

* Yes No

	Date of last check-up:	* day month year
	Results:	*

Eva Christen Doe (spouse)

* Yes No

	Date of last check-up:	* day month year
	Results:	*

Andreia Doe (child)

* Yes No

	Date of last check-up:	* day month year
	Results:	*

3.	* Within the last 12 months have you lost work due to illness or injury?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

4.	* Within the last three years have you been admitted to a hospital or clinic as a patient (except for pregnancy or birth) for longer than five consecutive days?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

5.	* Within the last three years have you received disability benefits for three months or longer?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

6.	* Within the last three years have you ever been declined for Life or Disability insurance?

Randy Doe (member)

* Yes No

	Name of insurer:	*
	Date declined:	* day month year
	Reason:	*

Eva Christen Doe (spouse)

* Yes No

	Name of insurer:	*
	Date declined:	* day month year
	Reason:	*

Andreia Doe (child)

* Yes No

	Name of insurer:	*
	Date declined:	* day month year
	Reason:	*

7.	* Within the last three years have you ever been offered Life or Disability insurance at a higher than standard risk?

Randy Doe (member)

* Yes No

	Name of insurer:	*
	Date:	* day month year
	Reason:	*

Eva Christen Doe (spouse)

* Yes No

	Name of insurer:	*
	Date:	* day month year
	Reason:	*

Andreia Doe (child)

* Yes No

	Name of insurer:	*
	Date:	* day month year
	Reason:	*

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