here is the EOI form they have, I have never applied ever: ...

Prompt

here is the EOI form they have, I have never applied ever: Long Term Income Protection (LTIP) Current Option No Coverage Requested Option Coverage Applicant Details INCOMPLETE FORMS WILL BE RETURNED To Be Completed By the Applicant — Statement of Health — Answer Every Question (Do not tell us about genetic testing or genetic test results) Please answer the following questions completely and accurately. If you're not sure whether some information is relevant, provide it anyway. If you do not disclose all relevant information, claims may be denied and insurance cancelled. Note: Questions 1 and 2 are not required if the application is for a child. 1. a) Height ______ m. ______ cm. ______ ft. ______ in. b) Weight ______ kg. ______ lbs. 2. Change in weight in the last 12 months ______ No change ______ Amount Gained (lbs/kg) ______ Amount Lost (lbs/kg) _____________________________________________ Reason for weight change 3. Date and reason for your last consultation with attending doctor (if no attending doctor, please state none) ________________________________________________________________________________ Long Term Income Protection Evidence of Insurability Page 3 4. Name of doctor, diagnosis, treatment given, results, medication prescribed (Do not tell us about genetic testing or genetic test results). ________________________________________________________________________________ 5. If the doctor named above does not have the most complete records of your medical history, please provide full name and address of the doctor who does have them. ________________________________________________________________________________ Long Term Income Protection Evidence of Insurability Page 4 Family History Information (Do not tell us about genetic testing or genetic test results) Yes No o o Have any of your immediate family members (parents, brothers, sisters) had a heart disease, heart attack, high blood pressure, polycystic kidney disease, familial polyposis of the bowel, stroke, diabetes, cancer (specify type below), multiple sclerosis, Huntington’s Chorea, Alzheimer’s, Parkinson’s, ALS (Amyotrophic Lateral Sclerosis) or any hereditary disease? If you answered “yes”, complete chart below. Do not tell us about genetic testing or genetic test results. Which condition(s) Age at onset Current age (if living) Age at death (if applicable) Father _______________________________ ____________ _____________ _____________ Mother _______________________________ ____________ _____________ _____________ Brother(s) _______________________________ ____________ _____________ _____________ Sister(s) _______________________________ ____________ _____________ _____________ Long Term Income Protection Evidence of Insurability Page 5 If you answer “yes” to any questions, please provide further details on the next page, including dates, treatment, medications and results but do not tell us about genetic testing or test results. Yes No o o 1. Have you ever been admitted to a hospital or clinic as a patient (except for pregnancy or birth) for longer than five consecutive days? o o 2. Have you ever received disability benefits for three months or longer? o o 3. Have you been declined or offered Life, Disability or Critical Illness Insurance at a higher than standard risk? Date: _________________ Reason: ___________________________________ Name of Insurance Company: ________________________________________________ o o 4. Have you used any nicotine products (tobacco, e-cigarettes, patches, etc.) within the last 12 months? o o 5. Within the last 10 years, have you used cocaine, hashish, heroin, narcotics, marijuana, LSD, hallucinogens, amphetamines, except as prescribed by a doctor, or sought or received advice or treatment for the use of drugs (over-the-counter, prescribed or non-prescribed)? o o 6. Do you consume alcoholic beverages? Average number of drinks per week: ________ o o 7. Have you ever been advised to stop drinking, to drink less or received treatment for use of alcohol? Who: _____________________________________ (e.g. spouse, friend, doctor, etc.) Reason: ___________________________________ Date (dd-mm-yyyy) _______ o o 8. Are you presently under medical treatment by diet, medicine or other means? (provide details including names of all medications and reason(s) why you are using them) o o 9. Have you ever had diabetes, impaired sugar levels or ever had sugar, blood or protein in your urine? What is your current treatment for diabetes? o o Insulin o o Oral Medication o o Diet Only Have you ever had or received treatment for, consulted a doctor or other health practitioner for, or been diagnosed as having any of the following: Yes No o o 10. Cancer, malignancy, leukemia, enlarged lymph nodes, lymph gland disorder, tumors, polyps or other growths including moles, breast lumps or cysts, had a biopsy for any reason or had an abnormal cancer screening test? o o 11. Illnesses of the heart or circulatory system, including chest pain, abnormal electrocardiogram (ECG), irregular pulse, heart murmur? Long Term Income Protection Evidence of Insurability Page 6 Yes No o o 12. Liver disorder or any type of hepatitis or blood disorders? o o 13. Disease or disorder of the kidneys, urinary tract, bladder, prostate or reproductive organs? o o 14. Chronic lung or respiratory disorder (including asthma and sleep apnea), disease or disorder of the eyes, ears, nose or throat? o o 15. Transient ischemic attack (TIA), paralysis, seizure, epilepsy, multiple sclerosis, Alzheimer’s, Parkinson’s or any other disease or disorder of the brain or nervous system? o o 16. Psychiatric or psychological problems (including anxiety, depression, panic attacks, eating disorders, any other emotional disorders) or been counselled for such? o o 17. Chronic fatigue syndrome, fibromyalgia, rheumatic/arthritic disease or lupus? o o 18. Musculoskeletal, joint or bone disorders, paralysis or numbness? o o 19. Back and neck problems? o o 20. High blood pressure? o o 21. High cholesterol? o o 22. Gastrointestinal disorder (including esophageal, stomach, colon, colitis or bowel/intestinal disorders)? o o 23. Have you ever tested positive for AIDS, ARC or HIV? o o 24. Have you ever suffered a heart attack or myocardial infarction? o o 25. Have you ever had a stroke? o o 26. Have you ever had an organ transplant? o o 27. Have you ever had any other illness, disease or disorder, condition, injury, diagnostic testing or surgical procedure not listed above? Do not take genetic testing or genetic test results into consideration. If, for example, you have not had any other illness, disorder, condition or surgery and you have only undergone genetic testing, then you can still answer “no”. o o 28. Have you ever used any special medical equipment or appliances such as a walker, cane, wheelchair, catheter, oxygen tank, pacemaker, artificial limb or hearing aid? o o 29. Do you require assistance of any kind to perform any daily activities, such as bathing, continence, dressing, eating, using the toilet or transferring (for example: bed to chair)? o o 30. Have you ever had any health symptoms or complaints for which a doctor has not been consulted or been advised to have further examinations or tests which have not been completed yet? Do not take genetic testing or genetic test results into consideration. If, for example, you have not had any other illness, disorder, condition or surgery and you have only undergone genetic testing, then you can still answer “no”. Long Term Income Protection Evidence of Insurability Page 7 Medical History Information (Do not tell us about genetic testing or genetic test results) For each “yes” answer above, please give full details below. If you require more space, please use a separate sheet of paper, but remember to date, sign and staple it to this form. Question Number __________ __________ __________ __________ __________ Details _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Long Term Income Protection Evidence of Insurability Page 8 Declaration and Authorization (please read and sign this section) I understand I may be refused those group benefits or any benefit amounts for which proof of good health is required if, in the opinion of Sun Life Assurance Company of Canada, I am not insurable. I certify that all the statements in this form are true and complete and I understand that concealment, misrepresentation and false declaration concerning this Health statement, will cause the insurance to be void. I authorize Sun Life Assurance Company of Canada, its agents and service providers to collect, use and disclose information needed for underwriting, administrating and adjudicating claims under this Plan with any person or organization who has relevant information about me and/or my dependents under age 18 (if applicable), pertaining to this Health statement. This includes any health professionals, institutions, investigative agencies, insurers and reinsurers. I agree that a photocopy of this authorization or electronic version is valid as the original and shall continue to have effect throughout the duration of my coverage under this group contract, unless withdrawn in writing. ____________________________________________________ Signature of Employee (required in all instances) ________________________________ Home Telephone Number* ____________________________________________________ Date ________________________________ Work Telephone Number* *In order to expedite the turnaround time of your form, please indicate the daytime telephone number where you prefer to be reached in the event that the underwriter needs to discuss or confirm details concerning health issues mentioned herein. Sun Life Assurance Company of Canada must receive your completed Health statement within 60 days of the date you complete, sign and date the form; otherwise you will need to submit a new Health statement. All information received by Sun Life Assurance Company of Canada is treated as strictly confidential and is used for the sole purpose of determining your eligibility and administering the group plan to which you belong. Returning your forms and medical information to us in a confidential envelope ensures that only our medical underwriters will have access to them. Long Term Income Protection Evidence of Insurability Page 9 You should keep a copy of this Health Questionnaire for your records and send the original in an envelope marked “Confidential” to: Sun Life Assurance Company of Canada Medical Underwriting Private and Confidential P.O. Box 578 STN C Waterloo Waterloo, ON N2J 4B8 my answers Sun Life LTIP — Evidence of Insurability Consolidated information prepared from the completed review of the form Applicant Details Height 5'9" Weight 215 lb Last consultation / reason Medication review/follow-up to optimize management of executive functioning, approximately one month after returning to work following a five-month absence. Attending doctor / most complete records Lindsay Damen — has my most complete medical records. Diagnosis / Treatment / Medication Autism Spectrum Disorder (ASD), with associated anxiety and depression. Medication management to optimize executive functioning. Current medications: Biphentin and atomoxetine. Ongoing psychotherapy. Family History Father: Rare cancer, discovered in the jaw and subsequently spread to the lungs. Diagnosed in 2003 at age 50. Non-aggressive cancer requiring repeated surgeries and radiation treatment for lung masses approximately every five years. Died in 2014 at age 61. Mother, brother(s), sister(s): No applicable condition reported. Medical History — Questions 1–30 # Answer Details 1 No 2 YES Temporary Disability Benefits (TDB) through employer. March 3, 2026 – August 2, 2026. Entire period covered by TDB. Nov 29, 2020 to May 2021 Second medical absence for acute anxiety and depression (GAD and acute depression, per Rob), within a 16-month period of severe family health crisis, while Rob's autism was still undiagnosed. Rob has chosen not to request these records. Graduated return to work arranged by the disability case manager (Health & Productivity Solution): from May 8, 2021, one set each at 6, 8 and 10 hours per shift, then regular full-time duties from June 1, 2021. 3 No 4 No 5 No 6 No / 0 drinks 7 No 8 YES Currently receiving medical treatment by medication and psychotherapy. Current medications: Biphentin and atomoxetine, used to optimize management of executive functioning. Ongoing psychotherapy. 9 No 10 No 11 No 12 No 13 No 14 No 15 No 16 YES Autism Spectrum Disorder (ASD), diagnosed October 2024. History of anxiety and depression associated with ASD. Ongoing psychotherapy and medication management. 17 No 18 No 19 No 20 No 21 No 22 No 23 No 24 No # Answer Details 25 No 26 No 27 YES 2012: Ultrasound; diagnosed with sports hernia. 2013: Laser eye surgery. 2016: Vandenbos procedure for ingrown toenail. COVID-19: Two infections. 28 No 29 No 30 No Medical History Information — Yes Answers Question 2 Temporary Disability Benefits (TDB) through employer. March 3, 2026 – August 2, 2026. Entire period covered by TDB. Question 8 Currently receiving medical treatment by medication and psychotherapy. Current medications: Biphentin and atomoxetine, used to optimize management of executive functioning. Ongoing psychotherapy. Question 16 Autism Spectrum Disorder (ASD), diagnosed October 2024. History of anxiety and depression associated with ASD. Ongoing psychotherapy and medication management. Question 27 2012: Ultrasound; diagnosed with sports hernia. 2013: Laser eye surgery. 2016: Vandenbos procedure for ingrown toenail. COVID-19: Two infections. Declaration / Submission Checklist • Transfer the information above to the current Sun Life EOI form. • Review every Yes/No response against the actual question before signing. • Sign and date the Health Statement. • Keep a complete copy for your records. • Submit within the form's stated 60-day period after completion, signing and dating. I should note that this is for LTIP and the EOI form required... I am also likely to head down path of EDB due to executive function / asd burnout etc, and that is supported by therapist, and have yet to fully discuss with NP [who would also be supportive] however this form will likely trigger NP records or a form,,, and then in the next 2-3 years she will be required to fill out EDB forms. I am wondering- should I even apply for LTIP? What are odds of approval here in canada via sunlife? and will this put NP in weird spot and later make EDB claim difficult with the same insurer here and for my NP to document ?