IMPORTANT DECLARATION

This declaration will determine your eligibility to qualify.

1.  Each person to be insured hereby declares the following:

1. 1. Never has had an application or a reinstatement of insurance that was declined, postponed, withdrawn or accepted with special conditions.
   2. That he/she has not been diagnosed or has consulted a health professional for one of the following conditions:
      Musculoskeletal Disorder (that caused the applicant to miss work in the last twelve (12) months) or that is requiring ongoing treatment by narcotics (such as: fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, dilaudid).
      Spine Diseases (causing the applicant to miss more than five (5) business days of work in the last twenty-four (24) months)
      Alzheimer's Disease or dementia
      Thoracic or Abdominal Aortic Aneurysm
      Rheumatoid Arthritis or Psoriatic Arthritis
      Liver Cirrhosis
      Cancer (diagnosed in the past 5 years, excluding basal cell carcinoma of the skin and cervical cancer in situ)
      Epilepsy (Grand mal, attack within 6 months)
      Chronic Fatigue Syndrome
      Fibromyalgia
      Chronic Renal Failure or Chronic Renal Disease
      Transient Ischemic Attack/Stroke
      Leukemia
      Lymphoma
      Systemic Lupus Erythematosus
      Heart Diseases (Angina Pectoris, Myocardial Infarction, Coronary Artery Bypass, Coronary Artery Angioplasty, Acute Coronary Syndrome) or Valvular Heart Disease (Including all Valvular Heart Disease)
      In the last 5 years you have not been in a drug rehabilitation program or been advised to do so or consumed: methamphetamine, cocaine, steroids or narcotics.
      Inflammatory Intestinal Disease (causing the applicant to miss more than fifteen (15) business days of work in the last twenty-four (24) months)
      Chronic Obstructive Pulmonary Disease
      Cystic Fibrosis
      Peripheral Vascular Disease
      Chronic Pancreatitis
      Parkinson's Disease
      Multiple Sclerosis
      Amyotrophic Lateral Sclerosis
      Acquired Immune Deficiency Syndrome (AIDS), HIV
      Myeloproliferative Syndrome
      Organ Transplants
      Breast Cancer
      Diabetes Mellitus (type 1 or 2)
      Hepatitis (B or C)
      Nervous disorders: Currently being treated or have been treated in the last 24 months for: depression, burnout, anxiety, chronic fatigue, attempted suicide, ADD/ADHD, eating disorders, delayed mental development, Schizophrenia or sleep disorder (including insomnia).
      In the last 5 years you have never received or been advised to undergo treatments or counselling for alcohol abuse or been charged with more than one DUI.
      In the last 5 years, you have never been charged, convicted or are awaiting trial for a criminal offence (excluding DUI).
   3. Not being hospitalized, awaiting hospitalization or disabled on the date of the signature of the present application;
   4. Have no pending medical examinations (other than for a common cold or annual physical examinations including routine blood work) or no current symptoms for which the client has not yet consulted a health care professional.