Option 1:

Standard Declaration


This declaration will determine your eligibility to qualify.

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

    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 Never has had an application or a reinstatement of insurance that was declined, postponed, withdrawn or accepted with special conditions.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.