Microsoft word - form vmd-1105 lori's draft apr 27.doc
Wealthlink Financial Group Inc. – Fillable Form
MEDICAL DECLARATION – Version V05
a) Complete for any applicant age 60 to 85 who is applying for the Stable Chronic Condition Option.
b) Complete for all applicants age 86 or over.
c) Agent must fax to 1-866-285-5727 or mail to 21st Century within 3 business days of making sale.
Agency Name ____________________________
Policy Number (if already issued on TIPS system)
__________________ Agent Ph #:____________________________
Name of Applicants (Last name, first name)
Date of Birth (mm/dd/yy)
MEDICAL DECLARATION - Not required if under age 60 or if waiving the Stable Chronic Condition coverage Option (Circle Yes or No)
Answer the following questions to determine eligibility.
1 Within the past 24 months
have you had any of the following:
a heart attack or congestive heart failure;
an organ or bone marrow transplant(excluding corneal transplant);
diagnosis or monitoring of, or treatment for a heart valve disorder; or
diagnosis or monitoring of, or treatment for a lung condition (excluding
2 Within the past 12 months
have you been diagnosed with, been hospitalized for,
taken or been prescribed medication for stroke, mini-stroke, or Transient Ischemic
3 Within the past 12 months
have you taken or been prescribed any of the following:
Lasix or furosemide or home oxygen for any reason;
prednisone for any lung condition (including
a heart condition (medication prescribed
for the control of blood pressure does not count as a medication for a heart
4 Within the past 6 months
have you consulted a doctor or used any prescribed
medication for any shortness of breath or chest pain, or used any form of
If unsure how to respond to any question, please consult a physician.
Age 60 to 85:
If you answer “No” to all questions, you are eligible to purchase the “Stable Chronic Condition” coverage option. Use Table 1 Rates. (If “Yes” responses or if waiving the “Stable Chronic Condition” coverage option, DO NOT submit this form, and use Table 2 Rates. Claims arising from “Stable Chronic Conditions” will not be paid.)
Age 86 or over:
If you answer “No” to all the questions, you are eligible to purchase this insurance. Claims arising from “Stable
Chronic Conditions” will not be paid. You are not eligible to purchase any coverage if you have any “Yes” responses.
I/we certify that the information provided on this form is true and accurate, and understand that such information is material to the risk, and constitutes the basis of any coverage offered. I/we fully understand that if any of my/our answers are untrue or incorrect, then coverage offered will be null and void. I/we understand that the policy contains important terms and conditions of coverage including exclusions and other limitations. I/we understand that Manulife Financial, its agents, third party administrators or its legal representatives may investigate any claim. I/we authorize any hospital, physician, or their medical service provider, or any other organization or person that has any records or knowledge of me/us and my/our health to release to third party administrators, and Manulife Financial and its reinsures, any such information for the purpose of this application, contract and any subsequent claim.
MUST be signed by the applicant or sponsor:
Name of Applicant/Sponsor (Print)
The 21st Century Travel Insurance (o/a 21st Century Travel Insurance Services in British Columbia) Visitors to Canada Insurance plan is underwritten by The Manufacturers Life Insurance Company
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