Asthma Bronchitis Questionnaire

Supplementary Questions concerning Asthma, Bronchitis or other Pulmonary Symptoms
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.

Information about the person being insured
Name (Last, First, Middle)
Policy No.
Client No.
New Business Office
The person being insured must answer the following questions. Please indicate details for each question on the space provided.

1. Briefly indicate the symptoms you

experienced in your last 3 attacks. (e.g.,

cough, sputum production, wheezing
respiration, shortness of breath and the
2. Do you have shortness of breath?
No
If “Yes”, describe the degree e.g., occuring on
ordinary activity or unaccustomed activity?)
No
Yes
No
Yes
No
No
b If cough is productive of sputum, describe
in details. (e.g., amount, color, any blood?)

4. a) Do you suffer from attacks of asthma or
If yes, how frequent are these attacks?
If yes, when was your last attack?
b Do the asthma attacks occur year-round
5. Do you regularly take any treatment or
No
No
No
No
If “Yes”, describe.
6. Have you undergone any special tests (other

than routine chest x-rays) to investigate your
No
If “Yes”, give details, dates, results.
7. State the name and address of your doctor and date last consulted.

MonthDayYear
Date
This section must be signed by the person

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
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