Address C P 3000 Levis Quebec G 6 V 9 X 8 web site desjardins life insurance dot com slash plan member Telephone 1 800 2 6 3 1 8 1 0 GROUP INSURANCE HEALTH AND LIFESTYLE QUESTIONNAIRE EVIDENCE OF INSURABILITY Desjardins insurance life health retirement logo Completing the questionnaire After completing the questionnaire • Answer all questions. • Keep a copy for your records. • Provide information only for the proposed insured person(s). • Attach a copy of your insurance application. • The proposed insured person(s) must read, physically sign and date the questionnaire. • Send the questionnaire and ...
Life Insurance Health Screening Questionnaire Client Name: ______________________________________________________________________ Agent Name: ______________________________________________________________________ Proposed Death Benefit Amount: ______________________________________________________ Type of Policy Seeking: ______________________________________________________________ Life Insurance is about protecting the things that are important to your clients. When considering life insurance for your client, you must think about their health. It is their health, not their pocketbook, that determines if life insurance makes sense. Date of Birth: _______________________ Height: ______________ Weight: _____________ Do you use tobacco products? Yes No Type: ______________________________ In past 12 months? Yes No How much? __________________________ Have you previously been declined for life insurance? Yes No Reason for decline: ...
OTHER HEALTH COVERAGE QUESTIONNAIRE Your contract contains a Coordination of Benefits (COB) provision to ensure correct benefits are provided on claims for members covered by more than one health insurance plan. We need information about possible other insurance coverage, including Medicare, before we can process your claims. Please complete this form and return it to the address listed on the bottom of this form. If you or a family member has Medicare or other coverage that has already provided benefits for these services, please attach the Explanation of Benefits notice to this form. If you have any questions or need ...
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