Sun Life Application Health Information
It is important that you provide complete and true information for us to assess your application. If you fail to provide all relevant information that you already know, future claims may be denied, the policy or rider may be declared void.
Name
First Name
Last Name
Health Information
Rows
Yes
No
101. Many people during their lifetime will experience or be treated for medical conditions. Please let us know which of the following you have had, or been told you had, or sought advise or treatment for: a. high blood pressure, chest pain/discomfort, heart murmur, rheumatic fever, stroke, aneurysm, circulatory or heart disorder?
b. diabetes, sugar in the urine, thyroid or other glandular (endocrine) disorder?
c. kidney, bladder or urinary disorder/infection, sexually transmitted disease, reproductive organ or prostate disorder?
d. disorders of the skin or pigmentation, enlarged glands or lymph nodes, nodules, polyps, cysts, lumps, tumor, mass, abnormal growth, cancer, malignancy, or any related conditions?
e. asthma, chronic cough pneumonia, tuberculosis, emphysema, or any other respiratory or lung disorder?
f. fainting spells, convulsion, developmental delay, epilepsy, seizure, tremor, loss of consciousness, paralysis, severe headache(s)or any other disorder of the brain or nervous system?
g. anxiety, depression, stress or any emotional/psychological, mental or psychiatric disorder?
h. ulcers, ulcerative colitis, intestinal bleeding, pancreatitis, hepatitis, cirrhosis, Chrohn's disease or other disorders of the stomach, digestive organ or liver?
i. arthritis or systematic lupus erythematosus, gout, back or spinal disorder, joint pain, multiple sclerosis, bone fracture, muscular weakness or muscle disorder?
j. anemia, bleeding, or blood disorder?
k. AIDS or positive HIV test?
l. any other illness or surgery?
102. Do you have any health symptoms, recurring or persistent pains, or complaints for which a physician has not been consulted or treatment has not been received?
103. Other than previously stated, have you within the past 5 years:
a. consulted any doctor or other health practitioner?
b. submitted to blood tests, ecg, x-rays, treadmill, echocardiogram, scans, MRI, ultrasounds, mammography, colonoscopy, biopsies or other tests?
c. attended or been admitted to any hospital or other medical facility?
If you answered "yes" to any of these questions, kindly provide details. Question No & Letter, Doctor's name and Clinic name or address
Date of last visit
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Month
-
Day
Year
Date
Reason for visit or diagnosis
Results of medical, laboratory tests, any advice or treatment received and results of treatment
Travel, Aviation, Hobbies and Lifestyle
on the Proposed Insured 16yo and above
Are you a Filipino citizen residing in the Philippines for less than 6 months, or are you a resident alien in the Philippines without a valid immigration status and have resided in the Philippines for less than 5 years?
*
Yes
No
In the last 12 months, have you travelled outside the Philippines for a period of more than 3 months, or do you intend to do so within the next 12 months?
*
Yes
No
In the last 2 years, have you flown as a pilot, crew member or flight attendant in a non-commercial flight of airplane?
*
Yes
No
In the last 2 years, have you engaged in scuba diving, automobile or motorcycle racing, sky diving, or other aerial activities, rock mountain climbing or other hazardous sports, or do you intend to do so in the next 12 months?
*
Yes
No
Do you drink more than 4 drinks* in a single day, or drink before or during work, or drink to cope with difficulties or depression, or combine alcohol with other drugs or certain prescription medications? *1 drink=330ml/bottle or beer or 148ml/shot of liquor
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Yes
No
In the last 5 years, have you used marijuana, shabu, ecstasy, cocaine, or LSD?
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Yes
No
In the last 5 years, have used other psychoactive drugs, heroin or other narcotics?
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Yes
No
Have you ever applied for or received a pension, payment or benefit due to injury, sickness or disability?
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Yes
No
Do you have any physical or mental condition which prevents or has prevented continuous full-time employment in your usual occupation?
*
Yes
No
In the last 10 years, have you declared or been petitioned for insolvency, or have been charged with or convicted with any criminal offense?
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Yes
No
Temporary Life Insurance Questions
If you answer "Yes" to any questions below, do not make a payment.
Have you ever applied for life or health insurance and been refused coverage?
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Yes
No
For the last 2 years, have you consulted a doctor for chest pain, stroke, heart attack, any other disease of the heart or cancer?
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Yes
No
Within the last 60 days, have you been admitted or advised to be admitted as an in-patient in a hospital or clinic (except for pregnancy, child birth or routine health check-up), or have you been advised to have any test or to undergo surgery?
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Yes
No
Is the applicant a female?
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Yes
No
Signature
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