DECLARATION OF INSURABILITY FOR APPLICATION TO REINSTATE
THE EQUITABLE LIFE INSURANCE COMPANY OF CANADA
370(2020/06/30) Page 3 of 8
Personal History
If “YES” answer to any questions 4.1 to 4.18, complete “Details” below.
Have you ever had symptoms of, been treated for, or been advised to receive treatment for, or had or been advised to have any investigations
or examinations with respect to questions 4.1 to 4.9 below?:
4.1 Heart attack, angina, chest pain, rheumatic fever, stroke, TIA, elevated blood pressure (last reading and date), or cholesterol, murmur,
or other heart or blood vessel disease or disorder? ………………………………………………………………
4.2 Asthma, respiratory, sleep apnea or other lung disorder? ……………………………………………………………
4.3 Hearing or visual impairments? ………………………………………………………………………………
4.4 Diabetes, colitis, bowel disorder, hepatitis, or hepatitis carrier state, kidney, bladder, prostate, gout, or urinary disorder, blood or
endocrine abnormality? ……………………………………………………………………………………
4.5 Thyroid or glandular disorder, lupus, MS, ALS, epilepsy, muscle or bone disorder? …………………………………………
4.6 Cancer, tumour, cyst, polyp, mole, lump or other growth, breast disorder or abnormal mammogram or ultrasond? ………………
4.7 Anxiety, depression, fatigue, stress, attempted suicide, nervous breakdown, eating disorder, or other nervous system disorder? ………
4.8 Optic neuritis, numbness, tingling, loss of balance, weakness of the extremities, visual disturbance or loss of sensation? ……………
4.9 The skin, muscles, bones and joints, e.g. arthritis, back or neck pain, paralysis, deformity, unusual skin lesions, unexplained infections,
or major organ transplantation? ... ……………………………………………………………………………
4.10 a) Have you ever been diagnosed or had treatment for, or have had any indication of possible exposure to AIDS (Acquired Immune
Deficiency Syndrome), ARC (AIDS Related Complex), or any other immunological disorder? ……………………………
b) Have you ever had a positive test result indicating exposure to the AIDS virus? ……………………………………
c) Within the past 5 years, have you had any indication of a sexually transmitted disease? ………………………………
4.11 Have you ever had any:
(If “YES”, advise type(s), date(s), reason(s), result(s).)
a) Electrocardiograms …………………………………………………………………………………
b) X-Rays ……………………………………………………………………………………………
c) Other Diagnostic Tests ………………………………………………………………………………
4.12 Have you ever had:
a) symptoms, illness, injury, surgery, treatment, examination or investigation; ………………………………………
b) or been advised to receive surgery, treatment, examination or investigation; ………………………………………
c) surgery, treatment, examination or investigation for which results are not yet known to you; which have not been disclosed
in questions 4.1 to 4.11 above? ………………………………………………………………………
4.13 Do you regularly take any medication?
(If “YES”, specify type, dosage, when and by whom prescribed.) ………………………………
4.14 Have you been absent from work as a result of illness or injury for 5 or more consecutive days within the past 5 years? ……………
4.15 Have you consulted any physician within the past 5 years for anything not covered in the above questions or in this Application?
(If “YES”, give particulars) ……………………………………………………………………………………
4.16 Are you aware of any symptoms or complaints regarding your health for which you have not yet consulted a physician? ……………
4.17 Have you been advised to have surgery, treatment or testing, which has not been completed? ………………………………
4.18 a) Do you drink alcoholic beverages?
(If “YES”, specify type and ounces per week.) …………………………………………
b) Have you ever received advice, treatment or counselling pertaining to your use of alcohol? ……………………………
c) Have you ever used marijuana, cocaine or any illegal or addictive drugs? …………………………………………
d) Have you ever received advice, treatment or counselling pertaining to your use of marijuana, cocaine or any illegal
or addictive drugs? …………………………………………………………………………………
LIFE 1 LIFE 2
YES NO YES NO
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4. STATEMENT OF HEALTH – NON MEDICAL (CONTINUED)