Supplementary Questions re Growths, Cysts, Lumps and Tumours

Please PRINT clearly. Use BLACK ink.

In this form, you and your refer to the person being insured, while we, us, our and the Company refer to Sun Life of Canada (Philippines), Inc., a member of the Sun Life Financial group of companies.
1. General Information

Information about the person being insured
Name (Last, First, Middle)
Policy No.
Client No.
New Business Office
2. Questions

The person being insured must answer the following questions. Please indicate details for each question on the space provided.
1. On what date was the growth discovered?

MonthDayYear
Date
2. a) Where is/was the precise location of the mass?
b) Is it still there or has it been removed?
3. If the growth has been removed, please tell us:
a) When?

MonthDayYear
Date
b) By whom? (indicate name and address of physician) and (names and address of hospital)
c) Where? (name and address of hospital, etc)
d) How? (e.g. local anaesthesia, full operation, cryosurgery)
e) How long were you off work?
f) What is the histopath report if any?
4. What treatment have you had following its removal? (e.g. tablets, radiotheraphy, etc)
5. What in medical terms was it called? (if known)
6. For how long were you followed up, and how often?
7. Are you being followed up or undergoing treatment now?
Yes
3. Signatures

You hereby agree that this forms part of your application for insurance on your life.
Place of Signing
Date of Signing (day/month/year)

MonthDayYear
Date
Signature of person being insured if age is 16 & over
Printed Name
Signature of parent if proposed insured is below 18 years old
Printed Name
An Online Form by Jojo Porquez.
Should be Empty:

1. General Information

2. Questions

3. Signatures