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HEALTH AND LIFESTYLE QUESTIONNAIRE A EVIDENCE OF INSURABILITY (Desjardins Insurace)

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GROUP INSURANCE
HEALTH AND LIFESTYLE
QUESTIONNAIRE
EVIDENCE OF INSURABILITY
Compleng the quesonnaire
• Answer all quesons.
• Provide informaon only for the proposed insured person(s).
• The proposed insured person(s) must read, physically sign and date the
quesonnaire.
Aer compleng the quesonnaire
• Keep a copy for your records.
• Aach a copy of your insurance applicaon.
• Send the quesonnaire and your insurance applicaon to:
Desjardins Assurances
C.P. 3000, Lévis (Québec) G6V 9X8
20009A (2020-03)
Page 1 of 4
B
IDENTIFICATION OF MEMBER
Last name and rst name
Contract number Division number Cercate number
Address - No., street, apt. City Province Postal code
Telephone numbers
Home (Area code + No.): Work (Area code + No.):
Occupaon:
This informaon is
required to process
your applicaon.
Place of birth (province, state, country) Are you presently working?
If so, number of hours worked - If not, state reason:
Yes No
C
IDENTIFICATION OF EMPLOYER
Name
Address - No., street,
oce City Province Postal code
D
IDENTIFICATION OF PROPOSED INSUREDS
MEMBER
Last name and rst name
Sex Date of birth Height Weight
Weight one year ago
Reason for change in weight (if applicable):
SPOUSE
Last name and rst name
Sex
Date of birth Height Weight
Weight one year ago
Reason for change in weight (if applicable):
CHILD
Last name and rst name
Sex
Date of birth Height Weight
Weight one year ago
Reason for change in weight (if applicable):
CHILD
Last name and rst name
Sex
Date of birth Height Weight
Weight one year ago
Reason for change in weight (if applicable):
CHILD
Last name and rst name
Sex
Date of birth Height Weight
Weight one year ago
Reason for change in weight (if applicable):
M F
YYYY MM DD
Ft in
M
Lb
Kg
YYYY MM DD
M F
1
YYYY MM DD
2
YYYY MM DD
3
YYYY MM DD
M F
M F
M F
A
REQUEST
Late applicaon
Addion of dependent without a life event
Request for amount of insurance in excess of the non-evidence maximum (see your booklet)
Request for oponal benet (evidence required)
Request for mandatory benet requiring evidence
Other:
Lb
Kg
Ft in
M
Lb
Kg
Lb
Kg
Ft in
M
Lb
Kg
Lb
Kg
Ft in
M
Lb
Kg
Lb
Kg
Ft in
M
Lb
Kg
Lb
Kg
Desjardins insurance life health rerement logo
Address C P 3000 Lévis Québec G 6 V 9 X 8 web site desjardins life insur-
ance dot com slash plan member Telephone 1 8 0 0 2 6 3 1 8 1 0
Page 2 of 4
No.
First name
Nature of illnesses, surgery, accidents, consultaons, Date Length of illness/
Lenght of hospitalizaon
Name and address of physicians
examinaons, treatments, medicaon, results disability (if applicable) or hospitals
YYYY MM DD
Days
Months
Years
Days
Months
Years
Days
Months
Years
Days
Months
Years
Days
Months
Years
Days
Months
Years
Days
Months
Years
Days
Months
Years
Days
Months
Years
Days
Months
Years
E
HEALTH QUESTIONNAIRE
COMPLETE FOR EACH PROPOSED INSURED.
MEMBER SPOUSE CHILDREN
1
Has the proposed insured had or do they currently have discomfort, signs or symptoms for which:
• They have not yet consulted a doctor?
Yes
No
Yes
No
Yes
No
2
3
In the last 5 years, has the proposed insured spent more than 72 hours:
• In a hospital, clinic or rehabilitaon facility for care not related to pregnancy or childbirth?
• In an alcohol, drug or gambling addicon treatment centre?
4
In the last 5 years, has the proposed insured been absent from work for health reasons other than maternity leave for
more than 4 consecuve weeks?
• Other illnesses or medical problems not listed above
5
In the last 2 years, has the proposed insured taken medicaon (not including contracepves, vitamins and natural
products) prescribed by a doctor for more than 4 consecuve weeks?
In the last 10 years, has the proposed insured consulted a health professional, been diagnosed, received treatment or
undergone surgery for any of the following:
• Abnormality of the immune system, including AIDS or a posive HIV test or other immunological infecon or
disorder
• Cancer, tumor, polyp or other malignant disease
• Endocrine system disorders, including diabetes, thyroid disease or other endocrine problems
• Lung disorders, including asthma, emphysema, pulmonary brosis, tuberculosis, sleep apnea or other chronic lung
or respiratory problems
• Cysc brosis
• Physical disorder, malformaon or inrmity
• Heart disease or problems with the circulatory system, including hypertension, infarct, angina, stroke, transient
ischemic aack (TIA) or other heart, blood vessel or circulatory problems
• Gastrointesnal disorders, including Crohn’s disease and ulcerave colis, hepas, hidden hepas, cirrhosis or
other liver, pancreas, stomach or intesnal problems
• Blood disorders, including anemia, leukemia, hemophilia or other blood problems
• Cerebral, neurological or psychological disorders, including epilepsy, convulsions, dizziness, loss of consciousness,
coma, depression, anxiety, eang disorders, job-related burnout, paralysis, mulple sclerosis, motor neuron
disorders, Alzheimer’s disease, Parkinson’s disease or other cerebral, nervous or psychological problems
• Neurological impairment, including ausm spectrum disorder, Re syndrome, cerebral palsy, muscular dystrophy,
hyperacvity, aenon decit disorder, delayed maturaon, intellectual disability
• Problems with kidneys, urinary tract, bladder, prostate, breasts (including abnormal mammogram or ultrasound)
or genitals (including abnormal PAP test) or presence of sugar, blood or protein in the urine
• Muscle, joint and bone condions, including chronic fague, bromyalgia, arthris, all forms of lupus, back or neck
pain, or other musculoskeletal problems
• Ear, nose and throat condions (not including os) or eye problems (not including myopia, presbyopia, hyperopia
and asgmasm)
• They are waing to see a specialist?
• They have consulted a doctor or other health professional and been advised to take medicaon, or undergo
tests or surgery that has yet to happen or for which they are currently awaing results?
Complete the table below for each queson to which the proposed insured answered yes. Use an addional sheet if needed.
Page 3 of 4
G
HISTORY
COMPLETE FOR EACH PROPOSED INSURED.
Is there any history in the family (father, mother, brothers, sisters) of heart disease, stroke, high cholesterol, high blood pressure, diabetes, kidney disease, mulple sclerosis,
Hunngton’s chorea, polyposis coli, cancer, Alzheimer’s disease, Parkinson’s disease, muscular dystrophy, motor neuron diseases or other hereditary diseases?
Yes
No
If yes, please complete the table below. For cancer, indicate the type.
Check the family member Illness(es) (if cancer: type)
Age at onset Age if Age
of the illness alive at death
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
Father
Mother
Brother
Sister
MEMBER
SPOUSE
CHILDREN
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
H AUTHORIZATION REGARDING YOUR PERSONAL INFORMATION
For the sole purpose of determining insurability, managing les and processing claims, I authorize Desjardins Insurance or its reinsurers: (a) to collect from any individual,
legal enty or public or parapublic organizaon only the personal informaon they have about me that is needed to process my le. This informaon may be collected from
third pares, including any health care professional or establishment, MIB, Inc., insurance and reinsurance companies, personal informaon brokers, invesgaon rms, the
contract holder, my employer or my former employers; (b) to disclose to those individuals, legal enes or public or parapublic organizaons only the personal informaon
they have about me that is needed to manage my le; (c) to request, if applicable, an invesgaon report about me and to use the personal informaon contained in other
les it may have that are now closed; (d) to disclose to my personal physician any medical informaon about me that was obtained during the evaluaon of my le; (e) to
disclose to other insurers or reinsurers any informaon about me that is relevant to determining my eligibility for insurance or for benets; (f) to provide a brief report on my
personal informaon, including my health informaon, to MIB, Inc. This authorizaon also applies to the collecon, use and communicaon of personal informaon regarding
my dependents, insofar as applicable to my claim. A photocopy of this authorizaon is as valid as the original.
Signature of member Date (YYYY - MM - DD)
Signature of spouse Signature of dependent children aged 18 and over to be
insured (aged 14 and over for Québec)
Remember your
signature and the
date!
F
LIFESTYLE QUESTIONNAIRE
COMPLETE FOR EACH PROPOSED INSURED.
MEMBER SPOUSE CHILDREN
In the last 10 years, has the proposed insured had an applicaon for insurance declined or modied, or approved with
an exclusion or extra premium?
If yes, indicate the reason and the dates:
1
2
In the last 5 years, has the proposed insured had their driver’s license suspended or revoked?
3
Has the proposed insured been accused or found guilty of a criminal act within the last 5 years?
4
In the last 12 months, has the proposed insured used any form of tobacco, including e-cigarees or other tobacco substutes?
5
Has the proposed insured received treatment for drug or alcohol addicon, or has a health professional recommended
that they reduce their drug or alcohol consumpon?
6
Tobacco?
Number of cigarees per day
E-cigarees?
Uses per day
Tobacco substute?
Uses per day
Alcoholic beverages?
Number of servings per week
Drugs or narcocs (including marijuana)?
Number of grams per week and product used
Yes
No
Yes
No
Yes
No
How much of the following does the proposed insured consume?
If none, indicate 0.
For alcoholic beverages, 1 serving =
1 bole of beer (8 ounces)
1 glass of wine (4 ounces)
2 ounces of spirits
Page 4 of 4
J PERSONAL INFORMATION MANAGEMENT
Desjardins Insurance handles the personal informaon it has on you in a condenal manner. Desjardins Insurance keeps this informaon on le so that you may benet from
group insurance services oered by the Company. This informaon is consulted solely by Desjardins Insurance employees who need to do so in the course of their work. Des-
jardins Insurance may compile anonymized personal informaon for stascal and informaonal purposes. Desjardins Insurance may also communicate with plan members
to provide them with opmal health management. You have the right to consult your le. You may also have informaon corrected if you demonstrate that it is inaccurate,
incomplete, ambiguous or not useful. To do so, you must send a wrien request to the following address: Privacy Ocer, Desjardins Insurance, 200, rue des Commandeurs,
Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list to oer its clients an insurance product following the terminaon of their group insurance. If you do not
wish to receive these oers, you may have your name removed from the list. To do so, you must send a wrien request to the Privacy Ocer at Desjardins Insurance. Desjar-
dins Insurance uses service providers located outside of Canada to perform certain specic acvies in its normal course of business. As such, it is possible that some of your
personal informaon may be transferred to another country and be subject to the laws of that country. For informaon about Desjardins Insurance’s policies and pracces in
terms of transferring personal informaon outside of Canada, visit the Desjardins Insurance website at www.desjardinslifeinsurance.com, or write to the Desjardins Insurance
Privacy Ocer at the address indicated above. The Privacy Ocer can also answer any quesons you may have about the transfer of personal informaon to service providers
located outside of Canada.
Informaon regarding the insurability of the person to be insured will be treated as condenal by Desjardins Insurance, its reinsurers and MIB, Inc., a non-prot membership
organizaon of insurance companies that operates an informaon exchange on behalf of its members. If you submit an applicaon for life or health insurance coverage for an
individual or a benet claim for an insured to another MIB, Inc. member company, upon request, MIB, Inc. will supply such company with the informaon it has on le about
this person. MIB, Inc. receives personal informaon for which the collecon, use and disclosure is governed by the Personal Informaon Protecon and Electronic Documents
Act (PIPEDA) and provincial laws. Accordingly, MIB, Inc. has agreed to protect such informaon in a manner that is substanally similar to Desjardins Insurance’s privacy and
personal informaon protecon pracces and in accordance with applicable laws. As a U.S.-based company, MIB, Inc. is also bound by U.S. laws regarding the disclosure of
personal informaon. If you have any quesons about MIB, Inc.’s commitment to ensuring the condenality of insureds’ personal informaon, contact the MIB, Inc. Privacy
Department at privacy@mib.com. Upon request, MIB, Inc. will disclose all of the informaon in an insured’s le to that insured. Insureds can contact MIB, Inc. at 416 597-
0590. Insureds who dispute the accuracy of the informaon MIB, Inc. has on record for them can seek a correcon in accordance with the procedures set forth on MIB, Inc.’s
Website at www.mib.com. They can also write to MIB, Inc.’s informaon oce at 330 University Avenue, Suite 501, Toronto, Ontario M5G 1R7. Desjardins Insurance and its
reinsurers can also release informaon from their les to other insurance companies to which an applicaon for life or health insurance or a benet claim has been submied.
Consumers can obtain addional informaon about MIB, Inc. at www.mib.com.
K NOTICE APPLICABLE TO MIB, INC.
I STATEMENT AND AUTHORIZATION REGARDING YOUR PERSONAL INFORMATION
I hereby cerfy that the answers given above are complete and true and I agree that they form an integral part of my applicaon for insurance. I hereby acknowledge that
I have read the noce regarding personal informaon management, as well as the noce regarding the MIB, Inc. and that I have received a copy thereof. The insurance will
become eecve on the date indicated on the contract. Any false declaraon may result in the cancellaon of the insurance. For the sole purpose of determining insurability,
managing les and processing claims, I authorize Desjardins Insurance or its reinsurers: (a) to collect from any individual, legal enty or public or parapublic organizaon only
the personal informaon they have about me that is needed to process my le. This informaon may be collected from third pares, including any health care professional or
establishment, MIB, Inc., insurance and reinsurance companies, personal informaon brokers, invesgaon rms, the contract holder, my employer or my former employers;
(b) to disclose to those individuals, legal enes or public or parapublic organizaons only the personal informaon they have about me that is needed to manage my le; (c)
to request, if applicable, an invesgaon report about me and to use the personal informaon contained in other les it may have that are now closed; (d) to disclose to my
personal physician any medical informaon about me that was obtained during the evaluaon of my le; (e) to disclose to other insurers or reinsurers any informaon about
me that is relevant to determining my eligibility for insurance or for benets; (f) to provide a brief report on my personal informaon, including my health informaon, to MIB,
Inc. This authorizaon also applies to the collecon, use and communicaon of personal informaon regarding my dependents, insofar as applicable to my claim. A photocopy
of this authorizaon is as valid as the original. If the Desjardins Insurance medical director deems appropriate, I authorize the medical director to send the informaon that
they obtained to analyze my applicaon or that supports the Company’s decision to the following physician:
Name and address of physician:
Remember your
signature and the
date!
Signature of member Date (YYYY - MM - DD)
Signature of spouse Signature of dependent children aged 18 and over to be
insured (aged 14 and over for Québec)
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HEALTH AND LIFESTYLE QUESTIONNAIRE A EVIDENCE OF INSURABILITY (Desjardins Insurace)

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Completed 9 February 2021

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