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 26 to 30 of 30

26.	* Have you ever tested positive for AIDS, ARC or HIV?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

27.	* Have you ever suffered a heart attack or myocardial infarction?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

28.	* Have you ever had a stroke?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

29.	* Have you ever had an organ transplant?

Randy Doe (member)

* Yes No

Eva Christen Doe (spouse)

* Yes No

Andreia Doe (child)

* Yes No

30.	* Do you have any other relevant comments you feel will be helpful as we assess your medical and lifestyle history?

* Yes No

Complete if providing evidence for dependent benefits.

I confirm that I have reviewed all 30 of the preceding questions with my spouse or dependent child who is 18 years or older. Each of them has specifically authorized me to provide the responses on their behalf, and I have recorded their responses accurately.

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