SIMPLIFIED INCOME (CRITICAL ILLNESS) INSURANCE QUESTIONS
Question
Yes
No
1.
Have you lived in Canada for less than 12 months?
2.
In the past two years, have you had an application for
critical illness insurance declined or postponed by any company including
industrial Alliance Pacific?
3.
Do you currently suffer from, or have you ever suffered from
or had symptoms of any of the following illnesses or ailments, or have you
ever consulted a doctor or been treated for:
a) Congenital cardiac defects, angina, angioplasty, coronary
artery bypass, heart attack, congestive heart failure, stroke, transient
ischemic attack (TIA) or any other cerebrovascular disease of the heart or
the blood vessels, or an abnormal electrocardiogram (ECG)?
b) Type 1 (insulin-dependent) diabetes or type 2 diabetes ?
c) Cancer or other malignant disease, tumour, colon polyp or
any other growth?
d) Any breast problems (mass, cyst, unusual discharge,
physical change, abnormal mammogram or biopsy) or prostate problems
(nodule or abnormal PSA)?
4.
a) Currently, are you under medical investigation or have you
been advised to undergo a diagnostic test or surgery that has not yet been
carried out?
b) Have you noticed any symptoms or health problems for which
you have not yet consulted a doctor, such as: abnormality, lump or mass on
the breasts, shortness of breath, chest pain, dizziness, loss of balance,
numbness, rectal bleeding, prostate or other problems?
5.
Have you tested positive for or received test results that
indicate the presence of any one of the following diseases:
a) HIV (AIDS virus), AIDS or other AIDS – related illness ?
b) Hepatitis B or C, chronic type D hepatitis, or carrier of
hepatitis B ?
6.
In the last five years, have you undergone detoxication
treatment (in-patient or out-patient treatment program) for alcohol or
drug use ?
7.
In the last five years, have you used hard drugs such as
opium, heroin, morphine, codeine, Demerol, barbiturates, amphetamines,
cocaine, hallucinogens or anabolic steroids, other than as prescribed by a
doctor, or methadone, whether prescribed by a doctor or not ?
8.
Family History
Do two (2) or more members of your immediate family (father,
mother, brothers, sisters) suffer from, or have they suffered from cancer,
heart disease, stroke or transient ischemic attack (TIA) before the age of
60 ?
9.
Does your current weight exceed the weight indicated for your
height in the table below?
Height
Weight Pounds
Height
Weight Kg
5'0" - 5'3"
208
150 – 162 cm
94
5'4" - 5'6"
230
163 – 169 cm
104
5'7" - 5'9"
250
170 – 177 cm
113
5'10" - 6'0"
270
178 – 183 cm
122
Over 6'0"
291
Over 183 cm
132
If you answered yes to one or more of the above questions, you are
not eligible for this insurance.
The Company reserves the right to carry out an assessment on
factors other than the one indicated above.
