group protection
TRANSCRIPT
Group ProtectionHealth Declaration
1
Important informationYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
If you are submitting this form on behalf of another person please contact us on 0345 223 8000 for help and advice
Why am I being asked to completethis formYour company has an insurance policy with Canada Life and you may be eligible for one or more of the following benefits as part of this
Life InsuranceA lump sum andor pension payable to your dependants if you die
Income ProtectionA proportion of your salary payable to you if you are off work ill for a defined period
Critical IllnessA lump sum payable to you if you are diagnosed with a defined serious illness eg heart attack cancer
If you return this completed Health Declaration to us we will be able to consider covering you for your full benefits
Helpful hints To help you accurately complete this form we have included some hints marked with a grey cross
bull We need you to complete and return this form so we can consider your full cover
bull We will not be able to consider your full cover until you are able to answer lsquoNorsquo to all five parts of the Covid-19 questions below
bull Please complete these questions when you are able to do so and then complete the rest of the form
bull To return your completed form or if you have any questions please see details in lsquoHow to return your formrsquo below
Covid-19 questionsHave any of the following applied to you in the last month
1 Irsquove tested positive for Coronavirus
2 Irsquove been advised to self-isolate (based on symptoms ndash this does not include social distancing orworking from home)
3 Irsquove had a new continuous cough andor high temperature
4 Irsquove had direct contact with someone whorsquos been confirmed or suspected to have Coronavirus
5 Irsquove had a combination of flu-like symptoms such as a sore throat headache fatigue body or joint pains fatigue shortness of breath or nauseavomitingdiarrhoea
Yes No Yes No
Yes No
Yes No
Yes No
If you have any questions regarding the completion of the form or the submission process please call us
Please mark as lsquoPrivate and Confidentialrsquo Scanned or photographed images of the completed form and any medical information can be emailed
How to return your form
Call us 0345 223 8000
By emailmedicalunderwriting canadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
2
Health DeclarationImportant information
Completing this form
Please make sure
You fully answer all questions
You tick one of the boxes in respect of your rights under
the Access to Medical Reports Act 1988
Read and Sign the Declaration and Consent on the
final page
You have completed any relevant hazardous pursuits
questionnaire(s)
Please ensure you have the following available when completing this declaration if applicable
Details of any medication that you are currently taking
Any recent medical examination test results from your GP or any other medical professional
Confidentiality statementWe take your confidentiality seriously and follow strict processes regarding the information you provide on this form and anything else we receive about you We have a confidentiality code of practice in place and all medical information is held securely Access is limited to authorised individuals who need to see it For reasons of added confidentiality you may wish to send part(s)all of this form marked Private and Confidential for the attention of the Medical Officer Such correspondence will only be opened by the AssistantChief Underwriter or Medical Underwriting Team Leader who act on the Medical Officerrsquos behalf and will supervise the underwriting until a final decision is made
Due to the challenges we are facing with the Covid 19 pandemic for a temporary period post intended for the Medical Officer may be opened by a wider group of individuals than stated above
Genetic testingIn accordance with the Association of British Insurerrsquos Code on Genetic Testing and Insurance you will only need to tell us about a genetic test result you have had because of a medical condition running in your family if both of the following apply
bull The test was for Huntingtonrsquos diseasebull The total life insurance you are insured for with
all companies is over pound500000
However you must tell us if you either have a family history of are experiencing symptoms of or are having treatment for a medical condition including any genetically inherited condition
If you wish to provide evidence about a favourable predictive genetic test result we will take this into account when assessing your cover
Health DeclarationPart 1 ndash Personal information
3
Will your occupation require you to travel or reside outside of Europe North America Australia or New Zealand within the next 12 months
Male Female
Surname
Name of the company you work for
What is your occupation
Forename(s)
Title What was your assigned sex at birth
Home address
If you have answered lsquoYesrsquo please complete the table below for each location otherwise continue to Part 2 Question 1
1 Your details
2 Occupation details
Helpful hint We may need to contact you during office hours so please provide the most convenient contact details
- -
Date of birth (day month year)
Helpful hint For example desk based travelling driving lifting operating machinery
Helpful hint If travel plans have not been finalised please advise likely destinations and durations
Helpful hint Please specify exact countries rather than eg Middle East Africa Asia South America
Yes No
Postcode
What activitiesduties are involved
Preferred telephone number and times to callPreferred email address
Please confirm your
Telephone callsWritten correspondance
If we do need to contact you please confirm how you wish to be addressed by us (eg first name title)
CountryCity or region of this country
Number of days you expect to be there in the next 12 months
Health DeclarationPart 2 ndash Medical details
4
Do you consult any other medical professionals Yes No
1
2
Doctorrsquos details
Recent medical examinations
Postcode
Name and address of your GP
If you have answered lsquoYesrsquo please provide contact details below
If you have answered lsquoYesrsquo to question 2a please complete questions b-d below
a
b
c
d
Have you had a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the last 12 months Please enclose a copy if available
Was any follow up suggested as a result of the medical examination
Did you attend these follow ups Yes
Yes No
Yes No
No
Helpful hint We may be able to save you time by using results from a medical examination you have already had rather than asking you to attend another
Helpful hint Medical Professional includes private Doctor Consultant Chiropractor Psychiatrist
If you have not enclosed a copy please advise contact details of the company who conducted the medical examination
What was the reason for these follow ups
Speciality
Email address
Speciality
Reason for consultation Reason for consultation
Postcode Postcode
Name and address of your consultantmedical professional Name and address of your consultantmedical professional
Health DeclarationPart 2 ndash Medical details
5
3 Future medical examinations
Are you intending to have a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the near future
If lsquoYesrsquo please advise
bull The name of the company who will be conducting the medical examination
bull The date you will be having this medical examination
We will contact you to advise next steps
Yes NoHelpful hint We may be able to save you time by using results from a medical examination you are intending to have rather than asking you to attend another
Company name
- -
Date
Health DeclarationPart 3 ndash Lifestyle information
6
1 Height and weight
What is your height
What is your weight
Amount changed by
orft ins m cms
or orst lbs kilos lbs
or orst lbs kilos lbs
Has your weight changed by 7lbs (3kgs) or more in the last six months
Has your weight increased or decreased
Yes No
Increased Decreased
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 2
Helpful hint Examples of weight change could include illness (please specify) diet stress lifestyle pregnancy exercise etc
What has caused this change
Helpful hint Alcohol in units (1 unit = 1 single pub measure of spirits small (125ml) glass of wine or frac12 pint of standard strength beer lager or cider)
Please advise your average weekly consumption of alcohol
Have you ever been advised to reduce or stop drinking alcohol by a medical professional
Please answer lsquoYesrsquo or lsquoNorsquo even if you donrsquot currently drink alcohol
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
2 Alcohol
Date of advice
Who gave the advice
Average units per week prior to advice
Reason for advice
units per week
- -
Health DeclarationPart 3 ndash Lifestyle information
7
3 Smoking
Current daily amount Daily amount 12 months ago
Have you used any form of tobacco or nicotine products within the last 12 months Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 4
Helpful hint Nicotine products could include patches chewing gum or e-cigarettes
Product(s) Product(s)
4 Recreational drugs
In the last 10 years have you used recreational drugs or injected non-prescription drugs (eg cannabis steroids cocaine heroin or ecstasy)
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 5
Approximate date from Approximate date from
Approximate date to Approximate date to
Drug Drug
Method of use Method of use
Frequency of use Frequency of use
- -
- -
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
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- What is your weight 5
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- Text Field 101011
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- Text Field 2015
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- Text Field 3010
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- Radio Button 2 Off
2
Health DeclarationImportant information
Completing this form
Please make sure
You fully answer all questions
You tick one of the boxes in respect of your rights under
the Access to Medical Reports Act 1988
Read and Sign the Declaration and Consent on the
final page
You have completed any relevant hazardous pursuits
questionnaire(s)
Please ensure you have the following available when completing this declaration if applicable
Details of any medication that you are currently taking
Any recent medical examination test results from your GP or any other medical professional
Confidentiality statementWe take your confidentiality seriously and follow strict processes regarding the information you provide on this form and anything else we receive about you We have a confidentiality code of practice in place and all medical information is held securely Access is limited to authorised individuals who need to see it For reasons of added confidentiality you may wish to send part(s)all of this form marked Private and Confidential for the attention of the Medical Officer Such correspondence will only be opened by the AssistantChief Underwriter or Medical Underwriting Team Leader who act on the Medical Officerrsquos behalf and will supervise the underwriting until a final decision is made
Due to the challenges we are facing with the Covid 19 pandemic for a temporary period post intended for the Medical Officer may be opened by a wider group of individuals than stated above
Genetic testingIn accordance with the Association of British Insurerrsquos Code on Genetic Testing and Insurance you will only need to tell us about a genetic test result you have had because of a medical condition running in your family if both of the following apply
bull The test was for Huntingtonrsquos diseasebull The total life insurance you are insured for with
all companies is over pound500000
However you must tell us if you either have a family history of are experiencing symptoms of or are having treatment for a medical condition including any genetically inherited condition
If you wish to provide evidence about a favourable predictive genetic test result we will take this into account when assessing your cover
Health DeclarationPart 1 ndash Personal information
3
Will your occupation require you to travel or reside outside of Europe North America Australia or New Zealand within the next 12 months
Male Female
Surname
Name of the company you work for
What is your occupation
Forename(s)
Title What was your assigned sex at birth
Home address
If you have answered lsquoYesrsquo please complete the table below for each location otherwise continue to Part 2 Question 1
1 Your details
2 Occupation details
Helpful hint We may need to contact you during office hours so please provide the most convenient contact details
- -
Date of birth (day month year)
Helpful hint For example desk based travelling driving lifting operating machinery
Helpful hint If travel plans have not been finalised please advise likely destinations and durations
Helpful hint Please specify exact countries rather than eg Middle East Africa Asia South America
Yes No
Postcode
What activitiesduties are involved
Preferred telephone number and times to callPreferred email address
Please confirm your
Telephone callsWritten correspondance
If we do need to contact you please confirm how you wish to be addressed by us (eg first name title)
CountryCity or region of this country
Number of days you expect to be there in the next 12 months
Health DeclarationPart 2 ndash Medical details
4
Do you consult any other medical professionals Yes No
1
2
Doctorrsquos details
Recent medical examinations
Postcode
Name and address of your GP
If you have answered lsquoYesrsquo please provide contact details below
If you have answered lsquoYesrsquo to question 2a please complete questions b-d below
a
b
c
d
Have you had a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the last 12 months Please enclose a copy if available
Was any follow up suggested as a result of the medical examination
Did you attend these follow ups Yes
Yes No
Yes No
No
Helpful hint We may be able to save you time by using results from a medical examination you have already had rather than asking you to attend another
Helpful hint Medical Professional includes private Doctor Consultant Chiropractor Psychiatrist
If you have not enclosed a copy please advise contact details of the company who conducted the medical examination
What was the reason for these follow ups
Speciality
Email address
Speciality
Reason for consultation Reason for consultation
Postcode Postcode
Name and address of your consultantmedical professional Name and address of your consultantmedical professional
Health DeclarationPart 2 ndash Medical details
5
3 Future medical examinations
Are you intending to have a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the near future
If lsquoYesrsquo please advise
bull The name of the company who will be conducting the medical examination
bull The date you will be having this medical examination
We will contact you to advise next steps
Yes NoHelpful hint We may be able to save you time by using results from a medical examination you are intending to have rather than asking you to attend another
Company name
- -
Date
Health DeclarationPart 3 ndash Lifestyle information
6
1 Height and weight
What is your height
What is your weight
Amount changed by
orft ins m cms
or orst lbs kilos lbs
or orst lbs kilos lbs
Has your weight changed by 7lbs (3kgs) or more in the last six months
Has your weight increased or decreased
Yes No
Increased Decreased
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 2
Helpful hint Examples of weight change could include illness (please specify) diet stress lifestyle pregnancy exercise etc
What has caused this change
Helpful hint Alcohol in units (1 unit = 1 single pub measure of spirits small (125ml) glass of wine or frac12 pint of standard strength beer lager or cider)
Please advise your average weekly consumption of alcohol
Have you ever been advised to reduce or stop drinking alcohol by a medical professional
Please answer lsquoYesrsquo or lsquoNorsquo even if you donrsquot currently drink alcohol
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
2 Alcohol
Date of advice
Who gave the advice
Average units per week prior to advice
Reason for advice
units per week
- -
Health DeclarationPart 3 ndash Lifestyle information
7
3 Smoking
Current daily amount Daily amount 12 months ago
Have you used any form of tobacco or nicotine products within the last 12 months Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 4
Helpful hint Nicotine products could include patches chewing gum or e-cigarettes
Product(s) Product(s)
4 Recreational drugs
In the last 10 years have you used recreational drugs or injected non-prescription drugs (eg cannabis steroids cocaine heroin or ecstasy)
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 5
Approximate date from Approximate date from
Approximate date to Approximate date to
Drug Drug
Method of use Method of use
Frequency of use Frequency of use
- -
- -
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Text Field 358
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- Text Field 368
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
- Check Box 264 Off
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- Text Field 1074
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- Text Field 1082
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- Text Field 73
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- What is your weight 5
- Check Box 274 Off
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- Text Field 1076
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- Text Field 1077
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- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 1021
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- Text Field 1020
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- Text Field 1019
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
- Text Field 1092
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- Text Field 338
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- Check Box 299 Off
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- Text Field 160
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- Text Field 1094
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- Text Field 164
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- Text Field 1098
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- Text Field 1099
- Text Field 10100
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- Check Box 301 Off
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- Text Field 176
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- Check Box 307 Off
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- Check Box 309 Off
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- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
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- Text Field 211
- Text Field 212
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- Text Field 101047
- Text Field 101048
- Text Field 221
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- Text Field 234
- Check Box 335 Off
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- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
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- Check Box 1031 Off
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- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
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- Text Field 244
- Text Field 604
- Text Field 101054
- Text Field 101056
- Text Field 606
- Text Field 608
- Text Field 101058
- Text Field 6011
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- Text Field 245
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- Text Field 255
- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
- Check Box 344 Off
- Check Box 1013 Off
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- Check Box 1021 Off
- Check Box 1022 Off
- Check Box 1037 Off
- Check Box 1038 Off
- Text Field 101028
- Text Field 257
- Text Field 258
- Text Field 259
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- Text Field 101030
- Text Field 101031
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- Text Field 272
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- Text Field 275
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- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
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- Text Field 101036
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- Text Field 314
- Check Box 347 Off
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- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
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- Text Field 101040
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- Text Field 101044
- Text Field 318
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- Text Field 5011
- Text Field 5012
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- Text Field 321
- Text Field 3014
- Text Field 2030
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 1 ndash Personal information
3
Will your occupation require you to travel or reside outside of Europe North America Australia or New Zealand within the next 12 months
Male Female
Surname
Name of the company you work for
What is your occupation
Forename(s)
Title What was your assigned sex at birth
Home address
If you have answered lsquoYesrsquo please complete the table below for each location otherwise continue to Part 2 Question 1
1 Your details
2 Occupation details
Helpful hint We may need to contact you during office hours so please provide the most convenient contact details
- -
Date of birth (day month year)
Helpful hint For example desk based travelling driving lifting operating machinery
Helpful hint If travel plans have not been finalised please advise likely destinations and durations
Helpful hint Please specify exact countries rather than eg Middle East Africa Asia South America
Yes No
Postcode
What activitiesduties are involved
Preferred telephone number and times to callPreferred email address
Please confirm your
Telephone callsWritten correspondance
If we do need to contact you please confirm how you wish to be addressed by us (eg first name title)
CountryCity or region of this country
Number of days you expect to be there in the next 12 months
Health DeclarationPart 2 ndash Medical details
4
Do you consult any other medical professionals Yes No
1
2
Doctorrsquos details
Recent medical examinations
Postcode
Name and address of your GP
If you have answered lsquoYesrsquo please provide contact details below
If you have answered lsquoYesrsquo to question 2a please complete questions b-d below
a
b
c
d
Have you had a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the last 12 months Please enclose a copy if available
Was any follow up suggested as a result of the medical examination
Did you attend these follow ups Yes
Yes No
Yes No
No
Helpful hint We may be able to save you time by using results from a medical examination you have already had rather than asking you to attend another
Helpful hint Medical Professional includes private Doctor Consultant Chiropractor Psychiatrist
If you have not enclosed a copy please advise contact details of the company who conducted the medical examination
What was the reason for these follow ups
Speciality
Email address
Speciality
Reason for consultation Reason for consultation
Postcode Postcode
Name and address of your consultantmedical professional Name and address of your consultantmedical professional
Health DeclarationPart 2 ndash Medical details
5
3 Future medical examinations
Are you intending to have a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the near future
If lsquoYesrsquo please advise
bull The name of the company who will be conducting the medical examination
bull The date you will be having this medical examination
We will contact you to advise next steps
Yes NoHelpful hint We may be able to save you time by using results from a medical examination you are intending to have rather than asking you to attend another
Company name
- -
Date
Health DeclarationPart 3 ndash Lifestyle information
6
1 Height and weight
What is your height
What is your weight
Amount changed by
orft ins m cms
or orst lbs kilos lbs
or orst lbs kilos lbs
Has your weight changed by 7lbs (3kgs) or more in the last six months
Has your weight increased or decreased
Yes No
Increased Decreased
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 2
Helpful hint Examples of weight change could include illness (please specify) diet stress lifestyle pregnancy exercise etc
What has caused this change
Helpful hint Alcohol in units (1 unit = 1 single pub measure of spirits small (125ml) glass of wine or frac12 pint of standard strength beer lager or cider)
Please advise your average weekly consumption of alcohol
Have you ever been advised to reduce or stop drinking alcohol by a medical professional
Please answer lsquoYesrsquo or lsquoNorsquo even if you donrsquot currently drink alcohol
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
2 Alcohol
Date of advice
Who gave the advice
Average units per week prior to advice
Reason for advice
units per week
- -
Health DeclarationPart 3 ndash Lifestyle information
7
3 Smoking
Current daily amount Daily amount 12 months ago
Have you used any form of tobacco or nicotine products within the last 12 months Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 4
Helpful hint Nicotine products could include patches chewing gum or e-cigarettes
Product(s) Product(s)
4 Recreational drugs
In the last 10 years have you used recreational drugs or injected non-prescription drugs (eg cannabis steroids cocaine heroin or ecstasy)
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 5
Approximate date from Approximate date from
Approximate date to Approximate date to
Drug Drug
Method of use Method of use
Frequency of use Frequency of use
- -
- -
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Text Field 144
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- Text Field 337
- Text Field 1091
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- Text Field 351
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- Text Field 160
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- Text Field 1094
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- Text Field 401
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- Text Field 1098
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- Text Field 1099
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- Check Box 301 Off
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- Text Field 176
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- Check Box 307 Off
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- Text Field 10105
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- Text Field 101011
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- Text Field 2015
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- Text Field 2021
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- Text Field 101045
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- Text Field 101047
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- Text Field 101020
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- Text Field 2022
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- Text Field 603
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- Text Field 3010
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- Radio Button 2 Off
Health DeclarationPart 2 ndash Medical details
4
Do you consult any other medical professionals Yes No
1
2
Doctorrsquos details
Recent medical examinations
Postcode
Name and address of your GP
If you have answered lsquoYesrsquo please provide contact details below
If you have answered lsquoYesrsquo to question 2a please complete questions b-d below
a
b
c
d
Have you had a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the last 12 months Please enclose a copy if available
Was any follow up suggested as a result of the medical examination
Did you attend these follow ups Yes
Yes No
Yes No
No
Helpful hint We may be able to save you time by using results from a medical examination you have already had rather than asking you to attend another
Helpful hint Medical Professional includes private Doctor Consultant Chiropractor Psychiatrist
If you have not enclosed a copy please advise contact details of the company who conducted the medical examination
What was the reason for these follow ups
Speciality
Email address
Speciality
Reason for consultation Reason for consultation
Postcode Postcode
Name and address of your consultantmedical professional Name and address of your consultantmedical professional
Health DeclarationPart 2 ndash Medical details
5
3 Future medical examinations
Are you intending to have a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the near future
If lsquoYesrsquo please advise
bull The name of the company who will be conducting the medical examination
bull The date you will be having this medical examination
We will contact you to advise next steps
Yes NoHelpful hint We may be able to save you time by using results from a medical examination you are intending to have rather than asking you to attend another
Company name
- -
Date
Health DeclarationPart 3 ndash Lifestyle information
6
1 Height and weight
What is your height
What is your weight
Amount changed by
orft ins m cms
or orst lbs kilos lbs
or orst lbs kilos lbs
Has your weight changed by 7lbs (3kgs) or more in the last six months
Has your weight increased or decreased
Yes No
Increased Decreased
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 2
Helpful hint Examples of weight change could include illness (please specify) diet stress lifestyle pregnancy exercise etc
What has caused this change
Helpful hint Alcohol in units (1 unit = 1 single pub measure of spirits small (125ml) glass of wine or frac12 pint of standard strength beer lager or cider)
Please advise your average weekly consumption of alcohol
Have you ever been advised to reduce or stop drinking alcohol by a medical professional
Please answer lsquoYesrsquo or lsquoNorsquo even if you donrsquot currently drink alcohol
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
2 Alcohol
Date of advice
Who gave the advice
Average units per week prior to advice
Reason for advice
units per week
- -
Health DeclarationPart 3 ndash Lifestyle information
7
3 Smoking
Current daily amount Daily amount 12 months ago
Have you used any form of tobacco or nicotine products within the last 12 months Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 4
Helpful hint Nicotine products could include patches chewing gum or e-cigarettes
Product(s) Product(s)
4 Recreational drugs
In the last 10 years have you used recreational drugs or injected non-prescription drugs (eg cannabis steroids cocaine heroin or ecstasy)
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 5
Approximate date from Approximate date from
Approximate date to Approximate date to
Drug Drug
Method of use Method of use
Frequency of use Frequency of use
- -
- -
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Text Field 358
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
- Check Box 274 Off
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- Text Field 144
- Text Field 1022
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Check Box 299 Off
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- Text Field 160
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- Text Field 1094
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- Text Field 164
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- Text Field 1098
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- Check Box 301 Off
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- Text Field 176
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- Check Box 307 Off
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- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
- Check Box 312 Off
- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
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- Text Field 204
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- Text Field 211
- Text Field 212
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- Text Field 214
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- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
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- Text Field 225
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- Text Field 227
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- Text Field 234
- Check Box 335 Off
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- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
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- Check Box 1025 Off
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- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
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- Text Field 604
- Text Field 101054
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- Text Field 606
- Text Field 608
- Text Field 101058
- Text Field 6011
- Text Field 6012
- Text Field 245
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- Text Field 249
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- Text Field 251
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- Text Field 253
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- Text Field 255
- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1013 Off
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- Check Box 1021 Off
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- Check Box 1037 Off
- Check Box 1038 Off
- Text Field 101028
- Text Field 257
- Text Field 258
- Text Field 259
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- Text Field 261
- Text Field 262
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- Text Field 264
- Text Field 265
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- Text Field 270
- Text Field 101030
- Text Field 101031
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- Text Field 275
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- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
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- Text Field 101036
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- Text Field 313
- Text Field 314
- Check Box 347 Off
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- Text Field 3010
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- Text Field 315
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- Text Field 501
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- Text Field 318
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- Text Field 5011
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- Text Field 321
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 2 ndash Medical details
5
3 Future medical examinations
Are you intending to have a BUPA Wellness medical or Nuffield screen (or similar) or an insurance medical in the near future
If lsquoYesrsquo please advise
bull The name of the company who will be conducting the medical examination
bull The date you will be having this medical examination
We will contact you to advise next steps
Yes NoHelpful hint We may be able to save you time by using results from a medical examination you are intending to have rather than asking you to attend another
Company name
- -
Date
Health DeclarationPart 3 ndash Lifestyle information
6
1 Height and weight
What is your height
What is your weight
Amount changed by
orft ins m cms
or orst lbs kilos lbs
or orst lbs kilos lbs
Has your weight changed by 7lbs (3kgs) or more in the last six months
Has your weight increased or decreased
Yes No
Increased Decreased
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 2
Helpful hint Examples of weight change could include illness (please specify) diet stress lifestyle pregnancy exercise etc
What has caused this change
Helpful hint Alcohol in units (1 unit = 1 single pub measure of spirits small (125ml) glass of wine or frac12 pint of standard strength beer lager or cider)
Please advise your average weekly consumption of alcohol
Have you ever been advised to reduce or stop drinking alcohol by a medical professional
Please answer lsquoYesrsquo or lsquoNorsquo even if you donrsquot currently drink alcohol
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
2 Alcohol
Date of advice
Who gave the advice
Average units per week prior to advice
Reason for advice
units per week
- -
Health DeclarationPart 3 ndash Lifestyle information
7
3 Smoking
Current daily amount Daily amount 12 months ago
Have you used any form of tobacco or nicotine products within the last 12 months Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 4
Helpful hint Nicotine products could include patches chewing gum or e-cigarettes
Product(s) Product(s)
4 Recreational drugs
In the last 10 years have you used recreational drugs or injected non-prescription drugs (eg cannabis steroids cocaine heroin or ecstasy)
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 5
Approximate date from Approximate date from
Approximate date to Approximate date to
Drug Drug
Method of use Method of use
Frequency of use Frequency of use
- -
- -
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
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- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
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- What is your weight 5
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- Radio Button 2 Off
Health DeclarationPart 3 ndash Lifestyle information
6
1 Height and weight
What is your height
What is your weight
Amount changed by
orft ins m cms
or orst lbs kilos lbs
or orst lbs kilos lbs
Has your weight changed by 7lbs (3kgs) or more in the last six months
Has your weight increased or decreased
Yes No
Increased Decreased
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 2
Helpful hint Examples of weight change could include illness (please specify) diet stress lifestyle pregnancy exercise etc
What has caused this change
Helpful hint Alcohol in units (1 unit = 1 single pub measure of spirits small (125ml) glass of wine or frac12 pint of standard strength beer lager or cider)
Please advise your average weekly consumption of alcohol
Have you ever been advised to reduce or stop drinking alcohol by a medical professional
Please answer lsquoYesrsquo or lsquoNorsquo even if you donrsquot currently drink alcohol
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
2 Alcohol
Date of advice
Who gave the advice
Average units per week prior to advice
Reason for advice
units per week
- -
Health DeclarationPart 3 ndash Lifestyle information
7
3 Smoking
Current daily amount Daily amount 12 months ago
Have you used any form of tobacco or nicotine products within the last 12 months Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 4
Helpful hint Nicotine products could include patches chewing gum or e-cigarettes
Product(s) Product(s)
4 Recreational drugs
In the last 10 years have you used recreational drugs or injected non-prescription drugs (eg cannabis steroids cocaine heroin or ecstasy)
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 5
Approximate date from Approximate date from
Approximate date to Approximate date to
Drug Drug
Method of use Method of use
Frequency of use Frequency of use
- -
- -
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Text Field 358
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- Text Field 368
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
- Check Box 264 Off
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- Text Field 1074
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- Text Field 73
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- What is your weight 5
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- Check Box 260 Off
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- Text Field 1077
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- Check Box 282 Off
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- Check Box 298 Off
- Text Field 144
- Text Field 1022
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- Text Field 142
- Text Field 1021
- Text Field 141
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- Text Field 1020
- Text Field 139
- Text Field 1019
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- Text Field 138
- Text Field 1017
- Text Field 1016
- Text Field 137
- Text Field 1015
- Text Field 1014
- Text Field 136
- Text Field 1011
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- Text Field 135
- Text Field 1010
- Text Field 1013
- Text Field 134
- Text Field 145
- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
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- Check Box 286 Off
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- Check Box 290 Off
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- Check Box 292 Off
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- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
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- Text Field 338
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- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
- Text Field 172
- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
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- Text Field 191
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
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- Text Field 10109
- Text Field 101010
- Text Field 194
- Text Field 205
- Text Field 195
- Text Field 196
- Text Field 197
- Text Field 198
- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
- Check Box 312 Off
- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
- Text Field 214
- Text Field 215
- Text Field 216
- Text Field 217
- Text Field 218
- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
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- Text Field 225
- Text Field 226
- Text Field 227
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- Text Field 229
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- Text Field 231
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- Text Field 233
- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
- Check Box 1027 Off
- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
- Text Field 237
- Text Field 238
- Text Field 239
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- Text Field 241
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- Text Field 604
- Text Field 101054
- Text Field 101056
- Text Field 606
- Text Field 608
- Text Field 101058
- Text Field 6011
- Text Field 6012
- Text Field 245
- Text Field 246
- Text Field 247
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- Text Field 250
- Text Field 251
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- Text Field 255
- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
- Check Box 344 Off
- Check Box 1013 Off
- Check Box 1014 Off
- Check Box 1015 Off
- Check Box 1016 Off
- Check Box 1017 Off
- Check Box 1018 Off
- Check Box 1021 Off
- Check Box 1022 Off
- Check Box 1037 Off
- Check Box 1038 Off
- Text Field 101028
- Text Field 257
- Text Field 258
- Text Field 259
- Text Field 260
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- Check Box 345 Off
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- Text Field 285
- Text Field 101033
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- Text Field 286
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- Text Field 3010
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 3 ndash Lifestyle information
7
3 Smoking
Current daily amount Daily amount 12 months ago
Have you used any form of tobacco or nicotine products within the last 12 months Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 4
Helpful hint Nicotine products could include patches chewing gum or e-cigarettes
Product(s) Product(s)
4 Recreational drugs
In the last 10 years have you used recreational drugs or injected non-prescription drugs (eg cannabis steroids cocaine heroin or ecstasy)
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 5
Approximate date from Approximate date from
Approximate date to Approximate date to
Drug Drug
Method of use Method of use
Frequency of use Frequency of use
- -
- -
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Radio Button 2 Off
Health DeclarationPart 3 ndash Lifestyle information
8
5 Hazardous pursuits
Do you take part in any of the hazardous pursuits listed below Yes NoHelpful hint We do not need to know about on-piste skiing holidays or if you have taken part in a one off event such as charity events or experience days
bull Aviation (not as a fare paying customer) or ballooning (excluding a one off event)
bull Diving eg cave wreck ice diving or diving deeper than 40m
bull Trans-ocean sailing or any type of racing
bull Equestrian sports (other than private hacking)
bull Hang glidingparagliding
bull Mountaineering or rock climbing
bull Motorsports (excluding track days)
bull Parachuting sky diving or base jumping (excluding a one off event)
bull Any other Extreme Pursuit
If you have answered lsquoYesrsquo please go to Document Library to find the relevant questionnaire complete it and return it with your Health Declaration
Our document library can be accessed at wwwcanadalifecouk
Please click on lsquoProtectionrsquo in the Header Bar and the Document Library can be accessed via the link at the bottom of the second column under Tools or alternatively click here
Please use the lsquoSearchrsquo bar to find the relevant questionnaire
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 1019
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- Text Field 136
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- Text Field 135
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- Text Field 1080
- Text Field 1081
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
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- Text Field 1094
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- Text Field 401
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- Text Field 1098
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- Text Field 175
- Text Field 1099
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- Check Box 301 Off
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- Text Field 176
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
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- Text Field 194
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- Text Field 101011
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- Text Field 2015
- Text Field 2017
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- Text Field 2021
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- Check Box 331 Off
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- Text Field 101045
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- Text Field 101047
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- Text Field 101020
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- Text Field 603
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- Text Field 3010
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- Radio Button 2 Off
Health DeclarationPart 4 ndash Family history
9
Question 1
Have your natural parents brothers or sisters had any of the conditions listed before the age of 65
Yes No UnknownHelpful hint We do not need to know about grandparents uncles or aunts
bull Alzheimerrsquos disease
bull Cancer
bull Diabetes
bull Familial adenomatous polyposis
bull Heart disease
bull Huntingtonrsquos disease
bull Multiple sclerosis
bull Muscular dystrophy
bull Motor neurone disease
bull Parkinsonrsquos disease
bull Polycystic kidney disease
bull Stroke
bull Any other hereditary disorder
If you have answered lsquoYesrsquo please complete the table below otherwise continue to Part 5 Question 1
Family member Condition (including the type of cancer or diabetes if applicable)
Age when diagnosed
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Text Field 358
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
- Check Box 264 Off
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- Text Field 1074
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- Text Field 73
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- What is your weight 5
- Check Box 274 Off
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- Text Field 1076
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- Text Field 1079
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- Text Field 1077
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- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 1021
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- Text Field 1020
- Text Field 139
- Text Field 1019
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- Text Field 138
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- Text Field 137
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- Text Field 136
- Text Field 1011
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- Text Field 135
- Text Field 1010
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- Text Field 134
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- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
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- Check Box 286 Off
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- Check Box 291 Off
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- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
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- Text Field 338
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
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- Text Field 1094
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- Text Field 164
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- Text Field 401
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- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
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- Check Box 301 Off
- Check Box 302 Off
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- Check Box 305 Off
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- Text Field 176
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- Check Box 307 Off
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- Text Field 10105
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- Text Field 194
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- Check Box 309 Off
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- Text Field 101011
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- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
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- Check Box 331 Off
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- Text Field 101045
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- Text Field 201
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- Text Field 101047
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- Check Box 335 Off
- Check Box 336 Off
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- Text Field 101020
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- Text Field 2022
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- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
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- Text Field 603
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- Text Field 604
- Text Field 101054
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- Check Box 343 Off
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- Check Box 345 Off
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- Text Field 285
- Text Field 101033
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- Text Field 286
- Text Field 101035
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- Text Field 101036
- Text Field 101037
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- Text Field 313
- Text Field 314
- Check Box 347 Off
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- Text Field 3010
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- Text Field 5010
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- Text Field 318
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- Text Field 5011
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- Text Field 321
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- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
10
Question 1
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 2
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Any disorder of the heart or circulatory disorders eg angina heart attack heart murmur cardiomyopathy or heart valve defect
Have you ever had or been diagnosed with any of the followingPlease complete all
YesNo boxes
Any disorder or injury of the brain brain haemorrhage stroke or TIA (transient ischaemic attacksmini strokes)
Any neurological disorder such as paralysis multiple sclerosis epilepsy Parkinsonrsquos optic neuritis muscular dystrophy dementia or Alzheimerrsquos disease
Any cancer Hodgkinrsquos disease lymphoma leukaemia or tumour
Any form of diabetes
Have you tested positive for any form of hepatitis or are you awaiting the result of such a test
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
- Check Box 397 Off
- Check Box 402 Off
- Check Box 403 Off
- Check Box 404 Off
- Check Box 405 Off
- Check Box 398 Off
- Check Box 399 Off
- Check Box 400 Off
- Check Box 401 Off
- Text Field 352
- Check Box 2 Off
- Check Box 3 Off
- Text Field 358
- Text Field 357
- Text Field 353
- Text Field 354
- Text Field 7
- Text Field 8
- Text Field 9
- Text Field 10
- Text Field 11
- Text Field 12
- Text Field 13
- Text Field 14
- Check Box 246 Off
- Check Box 247 Off
- Text Field 1071
- Text Field 1072
- Text Field 1073
- Text Field 10110
- Text Field 368
- Text Field 369
- Text Field 370
- Text Field 371
- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
- Check Box 264 Off
- Check Box 265 Off
- Check Box 266 Off
- Check Box 267 Off
- Check Box 268 Off
- Check Box 269 Off
- Check Box 270 Off
- Check Box 271 Off
- Text Field 1074
- Text Field 1075
- Text Field 69
- Text Field 378
- Text Field 70
- Text Field 71
- Text Field 72
- Text Field 1082
- Text Field 1086
- Text Field 1085
- Text Field 1087
- Text Field 1083
- Text Field 1088
- Text Field 1084
- Text Field 1089
- Text Field 1068
- Text Field 1069
- Text Field 1070
- Check Box 272 Off
- Check Box 273 Off
- Text Field 73
- Text Field 74
- Text Field 75
- Text Field 76
- Text Field 77
- Text Field 78
- Text Field 79
- Text Field 80
- Text Field 81
- What is your weight 5
- Check Box 274 Off
- Check Box 275 Off
- Check Box 276 Off
- Check Box 277 Off
- Text Field 1076
- Text Field 82
- Text Field 83
- Text Field 84
- Text Field 85
- Text Field 86
- Text Field 87
- Text Field 88
- Text Field 89
- Text Field 90
- Text Field 91
- Text Field 92
- Check Box 278 Off
- Check Box 279 Off
- Text Field 93
- Text Field 94
- Text Field 1079
- Text Field 95
- Text Field 96
- Text Field 97
- Text Field 98
- Text Field 99
- Text Field 100
- Text Field 101
- Text Field 102
- Text Field 103
- Check Box 260 Off
- Check Box 261 Off
- Text Field 1077
- Text Field 1078
- Text Field 37
- Text Field 38
- Check Box 262 Off
- Check Box 263 Off
- Text Field 39
- Text Field 40
- Text Field 41
- Text Field 42
- Text Field 43
- Text Field 44
- Text Field 45
- Text Field 46
- Text Field 47
- Text Field 48
- Text Field 49
- Text Field 50
- Text Field 51
- Text Field 52
- Text Field 53
- Text Field 54
- Text Field 55
- Text Field 56
- Text Field 57
- Text Field 58
- Text Field 59
- Text Field 60
- Text Field 61
- Text Field 62
- Text Field 63
- Text Field 64
- Text Field 65
- Text Field 66
- Text Field 67
- Text Field 68
- Check Box 282 Off
- Check Box 283 Off
- Check Box 284 Off
- Check Box 285 Off
- Check Box 298 Off
- Text Field 144
- Text Field 1022
- Text Field 143
- Text Field 142
- Text Field 1021
- Text Field 141
- Text Field 140
- Text Field 1020
- Text Field 139
- Text Field 1019
- Text Field 1018
- Text Field 138
- Text Field 1017
- Text Field 1016
- Text Field 137
- Text Field 1015
- Text Field 1014
- Text Field 136
- Text Field 1011
- Text Field 1012
- Text Field 135
- Text Field 1010
- Text Field 1013
- Text Field 134
- Text Field 145
- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
- Text Field 147
- Text Field 148
- Text Field 149
- Text Field 150
- Text Field 151
- Text Field 152
- Text Field 153
- Text Field 154
- Text Field 155
- Text Field 156
- Text Field 157
- Text Field 158
- Text Field 159
- Check Box 286 Off
- Check Box 287 Off
- Check Box 288 Off
- Check Box 289 Off
- Check Box 290 Off
- Check Box 291 Off
- Check Box 292 Off
- Check Box 293 Off
- Check Box 294 Off
- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
- Text Field 1093
- Text Field 338
- Text Field 339
- Text Field 340
- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
- Text Field 348
- Text Field 349
- Text Field 350
- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
- Text Field 172
- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
- Text Field 178
- Text Field 179
- Text Field 180
- Text Field 181
- Text Field 182
- Text Field 183
- Text Field 184
- Text Field 185
- Text Field 186
- Text Field 187
- Text Field 188
- Text Field 189
- Text Field 190
- Text Field 191
- Text Field 192
- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
- Text Field 10107
- Text Field 10109
- Text Field 101010
- Text Field 194
- Text Field 205
- Text Field 195
- Text Field 196
- Text Field 197
- Text Field 198
- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
- Check Box 312 Off
- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
- Text Field 214
- Text Field 215
- Text Field 216
- Text Field 217
- Text Field 218
- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
- Text Field 224
- Text Field 225
- Text Field 226
- Text Field 227
- Text Field 228
- Text Field 229
- Text Field 230
- Text Field 231
- Text Field 232
- Text Field 233
- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
- Check Box 1027 Off
- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
- Text Field 237
- Text Field 238
- Text Field 239
- Text Field 240
- Text Field 241
- Text Field 242
- Text Field 243
- Text Field 244
- Text Field 604
- Text Field 101054
- Text Field 101056
- Text Field 606
- Text Field 608
- Text Field 101058
- Text Field 6011
- Text Field 6012
- Text Field 245
- Text Field 246
- Text Field 247
- Text Field 248
- Text Field 249
- Text Field 250
- Text Field 251
- Text Field 252
- Text Field 253
- Text Field 254
- Text Field 255
- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
- Check Box 344 Off
- Check Box 1013 Off
- Check Box 1014 Off
- Check Box 1015 Off
- Check Box 1016 Off
- Check Box 1017 Off
- Check Box 1018 Off
- Check Box 1021 Off
- Check Box 1022 Off
- Check Box 1037 Off
- Check Box 1038 Off
- Text Field 101028
- Text Field 257
- Text Field 258
- Text Field 259
- Text Field 260
- Text Field 261
- Text Field 262
- Text Field 263
- Text Field 264
- Text Field 265
- Text Field 266
- Text Field 267
- Text Field 268
- Text Field 269
- Text Field 270
- Text Field 101030
- Text Field 101031
- Text Field 271
- Text Field 101032
- Text Field 272
- Text Field 273
- Text Field 274
- Text Field 275
- Text Field 276
- Text Field 277
- Text Field 278
- Text Field 279
- Text Field 280
- Text Field 281
- Text Field 282
- Text Field 283
- Text Field 284
- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
- Text Field 288
- Text Field 289
- Text Field 290
- Text Field 291
- Text Field 292
- Text Field 293
- Text Field 294
- Text Field 295
- Text Field 296
- Text Field 297
- Text Field 298
- Text Field 299
- Text Field 300
- Text Field 101036
- Text Field 101037
- Text Field 301
- Text Field 101038
- Text Field 302
- Text Field 303
- Text Field 304
- Text Field 305
- Text Field 306
- Text Field 307
- Text Field 308
- Text Field 309
- Text Field 310
- Text Field 311
- Text Field 312
- Text Field 313
- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
- Check Box 349 Off
- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
- Text Field 316
- Text Field 317
- Text Field 501
- Text Field 502
- Text Field 503
- Text Field 504
- Text Field 505
- Text Field 506
- Text Field 507
- Text Field 508
- Text Field 509
- Text Field 5010
- Text Field 3012
- Text Field 101040
- Text Field 101042
- Text Field 3013
- Text Field 101044
- Text Field 318
- Text Field 319
- Text Field 320
- Text Field 5011
- Text Field 5012
- Text Field 5013
- Text Field 5014
- Text Field 5015
- Text Field 5016
- Text Field 5017
- Text Field 5018
- Text Field 5019
- Text Field 5020
- Text Field 321
- Text Field 3014
- Text Field 2030
- Text Field 2031
- Text Field 2032
- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
11
Question 1 ndash continued
Condition andor type
Investigations conducted
Results of these investigations
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Check Box 403 Off
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- Check Box 399 Off
- Check Box 400 Off
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- Text Field 352
- Check Box 2 Off
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- Text Field 358
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- Text Field 7
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- Check Box 246 Off
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- Text Field 1071
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- Text Field 371
- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- Text Field 1074
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- Text Field 1070
- Check Box 272 Off
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- Text Field 73
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- Text Field 81
- What is your weight 5
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- Text Field 1076
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- Check Box 278 Off
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- Text Field 93
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- Text Field 1079
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- Check Box 260 Off
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- Text Field 1077
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- Check Box 262 Off
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- Text Field 68
- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 1021
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- Text Field 1020
- Text Field 139
- Text Field 1019
- Text Field 1018
- Text Field 138
- Text Field 1017
- Text Field 1016
- Text Field 137
- Text Field 1015
- Text Field 1014
- Text Field 136
- Text Field 1011
- Text Field 1012
- Text Field 135
- Text Field 1010
- Text Field 1013
- Text Field 134
- Text Field 145
- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
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- Text Field 159
- Check Box 286 Off
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- Check Box 289 Off
- Check Box 290 Off
- Check Box 291 Off
- Check Box 292 Off
- Check Box 293 Off
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- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
- Text Field 1093
- Text Field 338
- Text Field 339
- Text Field 340
- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
- Text Field 348
- Text Field 349
- Text Field 350
- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
- Text Field 172
- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
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- Text Field 187
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- Text Field 189
- Text Field 190
- Text Field 191
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
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- Text Field 101010
- Text Field 194
- Text Field 205
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- Text Field 199
- Text Field 200
- Check Box 309 Off
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- Check Box 319 Off
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- Check Box 326 Off
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- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
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- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
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- Text Field 101047
- Text Field 101048
- Text Field 221
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- Check Box 335 Off
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- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
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- Text Field 2022
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- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
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- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
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- Text Field 101057
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- Text Field 6010
- Text Field 235
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- Text Field 604
- Text Field 101054
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- Text Field 6011
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Text Field 101028
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- Check Box 345 Off
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- Text Field 285
- Text Field 101033
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- Text Field 101036
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- Check Box 347 Off
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- Text Field 3010
- Text Field 101039
- Text Field 101041
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- Text Field 315
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
12
Question 2
Has any application for life health medical or critical illness insurance ever been declined postponed withdrawn or accepted with an additional premium Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Question 3
Insurance company Insurance company
Insurance product Insurance product
Decision Decision
Reason for decision Reason for decision
Approximate dates Approximate dates
Please attach copies of any related correspondence
- -
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Text Field 144
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
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- Text Field 1094
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- Text Field 164
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- Text Field 401
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- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
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- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
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- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
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- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
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- Text Field 194
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- Check Box 309 Off
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- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
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- Check Box 319 Off
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- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
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- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
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- Text Field 215
- Text Field 216
- Text Field 217
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- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
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- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
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- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
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- Text Field 604
- Text Field 101054
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- Text Field 101058
- Text Field 6011
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- Text Field 245
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1013 Off
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- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
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- Text Field 101036
- Text Field 101037
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- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
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- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
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- Text Field 101040
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- Text Field 318
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- Text Field 5011
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
13
In the last 5 years have you had any nervous disorders including anxiety stress depression chronic fatigue syndrome or eating disorders
Yes No
Have you ever been diagnosed with any mental or behavioural disorder that has required hospital treatment or referral to a psychiatrist or other specialist
Yes No
If you have answered lsquoYesrsquo to either or both of the above please complete the questions below otherwise continue to Part 5 Question 4
Condition
Number of occurrencesApproximate time off work in the last 5 years due to this condition
What is your understanding of the cause
Please describe the symptoms and any impact on your daily activities
What actions have you taken to reduce or eliminate the cause of these symptoms
What treatment have you received to date If none please state none
What type(s) of medical professional have you seen for this (eg General Practitioner psychiatrist counsellor)
What treatment are you currently receiving If none please state noneApproximate date of last symptoms
If lsquoYesrsquo please advise approximate monthyear
Please attach copies of any related correspondence
Have you ever thought about or attempted to harm yourself or tried to take your own life Yes No
Question 3
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
-
Approximate date of first symptoms
-
-
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Text Field 358
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- Text Field 73
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- What is your weight 5
- Check Box 274 Off
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- Text Field 1076
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- Text Field 1077
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- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 1020
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Check Box 299 Off
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- Text Field 160
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- Text Field 1094
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- Text Field 164
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- Text Field 1098
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- Text Field 1099
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- Check Box 301 Off
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- Text Field 176
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- Check Box 307 Off
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- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
- Check Box 312 Off
- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
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- Check Box 323 Off
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- Check Box 325 Off
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- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
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- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
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- Text Field 214
- Text Field 215
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- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
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- Text Field 225
- Text Field 226
- Text Field 227
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- Text Field 229
- Text Field 230
- Text Field 231
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- Text Field 233
- Text Field 234
- Check Box 335 Off
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- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
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- Text Field 603
- Text Field 101053
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- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
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- Text Field 604
- Text Field 101054
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- Text Field 101029
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- Text Field 256
- Check Box 343 Off
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- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
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- Text Field 285
- Text Field 101033
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- Text Field 101036
- Text Field 101037
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- Text Field 305
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- Text Field 314
- Check Box 347 Off
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- Text Field 3010
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- Text Field 315
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- Text Field 5010
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- Text Field 5011
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- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
14
In the last 5 years have you had any pain or disorder relating to your back neck joints bones or muscles including arthritis or rheumatism
Yes No
If you have answered lsquoYesrsquo please complete the questions below otherwise continue to Part 5 Question 5
Question 4
Name of disorder
What is your understanding of the cause of your paindisorder
Location of pain eg lower back knee hip shoulder etc
Which side of the body (if applicable) eg left right both
What activities make your pain worse (eg driving flying sitting)
What have you done to cope with these activities
Number of occurrences
Time off work in the last 5 years due to this condition
Approximate date of first symptoms
-
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
- Check Box 397 Off
- Check Box 402 Off
- Check Box 403 Off
- Check Box 404 Off
- Check Box 405 Off
- Check Box 398 Off
- Check Box 399 Off
- Check Box 400 Off
- Check Box 401 Off
- Text Field 352
- Check Box 2 Off
- Check Box 3 Off
- Text Field 358
- Text Field 357
- Text Field 353
- Text Field 354
- Text Field 7
- Text Field 8
- Text Field 9
- Text Field 10
- Text Field 11
- Text Field 12
- Text Field 13
- Text Field 14
- Check Box 246 Off
- Check Box 247 Off
- Text Field 1071
- Text Field 1072
- Text Field 1073
- Text Field 10110
- Text Field 368
- Text Field 369
- Text Field 370
- Text Field 371
- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
- Check Box 264 Off
- Check Box 265 Off
- Check Box 266 Off
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- Text Field 1074
- Text Field 1075
- Text Field 69
- Text Field 378
- Text Field 70
- Text Field 71
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- Text Field 1082
- Text Field 1086
- Text Field 1085
- Text Field 1087
- Text Field 1083
- Text Field 1088
- Text Field 1084
- Text Field 1089
- Text Field 1068
- Text Field 1069
- Text Field 1070
- Check Box 272 Off
- Check Box 273 Off
- Text Field 73
- Text Field 74
- Text Field 75
- Text Field 76
- Text Field 77
- Text Field 78
- Text Field 79
- Text Field 80
- Text Field 81
- What is your weight 5
- Check Box 274 Off
- Check Box 275 Off
- Check Box 276 Off
- Check Box 277 Off
- Text Field 1076
- Text Field 82
- Text Field 83
- Text Field 84
- Text Field 85
- Text Field 86
- Text Field 87
- Text Field 88
- Text Field 89
- Text Field 90
- Text Field 91
- Text Field 92
- Check Box 278 Off
- Check Box 279 Off
- Text Field 93
- Text Field 94
- Text Field 1079
- Text Field 95
- Text Field 96
- Text Field 97
- Text Field 98
- Text Field 99
- Text Field 100
- Text Field 101
- Text Field 102
- Text Field 103
- Check Box 260 Off
- Check Box 261 Off
- Text Field 1077
- Text Field 1078
- Text Field 37
- Text Field 38
- Check Box 262 Off
- Check Box 263 Off
- Text Field 39
- Text Field 40
- Text Field 41
- Text Field 42
- Text Field 43
- Text Field 44
- Text Field 45
- Text Field 46
- Text Field 47
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- Text Field 49
- Text Field 50
- Text Field 51
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- Text Field 53
- Text Field 54
- Text Field 55
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- Text Field 57
- Text Field 58
- Text Field 59
- Text Field 60
- Text Field 61
- Text Field 62
- Text Field 63
- Text Field 64
- Text Field 65
- Text Field 66
- Text Field 67
- Text Field 68
- Check Box 282 Off
- Check Box 283 Off
- Check Box 284 Off
- Check Box 285 Off
- Check Box 298 Off
- Text Field 144
- Text Field 1022
- Text Field 143
- Text Field 142
- Text Field 1021
- Text Field 141
- Text Field 140
- Text Field 1020
- Text Field 139
- Text Field 1019
- Text Field 1018
- Text Field 138
- Text Field 1017
- Text Field 1016
- Text Field 137
- Text Field 1015
- Text Field 1014
- Text Field 136
- Text Field 1011
- Text Field 1012
- Text Field 135
- Text Field 1010
- Text Field 1013
- Text Field 134
- Text Field 145
- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
- Text Field 147
- Text Field 148
- Text Field 149
- Text Field 150
- Text Field 151
- Text Field 152
- Text Field 153
- Text Field 154
- Text Field 155
- Text Field 156
- Text Field 157
- Text Field 158
- Text Field 159
- Check Box 286 Off
- Check Box 287 Off
- Check Box 288 Off
- Check Box 289 Off
- Check Box 290 Off
- Check Box 291 Off
- Check Box 292 Off
- Check Box 293 Off
- Check Box 294 Off
- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
- Text Field 1093
- Text Field 338
- Text Field 339
- Text Field 340
- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
- Text Field 348
- Text Field 349
- Text Field 350
- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
- Text Field 172
- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
- Text Field 178
- Text Field 179
- Text Field 180
- Text Field 181
- Text Field 182
- Text Field 183
- Text Field 184
- Text Field 185
- Text Field 186
- Text Field 187
- Text Field 188
- Text Field 189
- Text Field 190
- Text Field 191
- Text Field 192
- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
- Text Field 10107
- Text Field 10109
- Text Field 101010
- Text Field 194
- Text Field 205
- Text Field 195
- Text Field 196
- Text Field 197
- Text Field 198
- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
- Check Box 312 Off
- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
- Text Field 214
- Text Field 215
- Text Field 216
- Text Field 217
- Text Field 218
- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
- Text Field 224
- Text Field 225
- Text Field 226
- Text Field 227
- Text Field 228
- Text Field 229
- Text Field 230
- Text Field 231
- Text Field 232
- Text Field 233
- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
- Check Box 1027 Off
- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
- Text Field 237
- Text Field 238
- Text Field 239
- Text Field 240
- Text Field 241
- Text Field 242
- Text Field 243
- Text Field 244
- Text Field 604
- Text Field 101054
- Text Field 101056
- Text Field 606
- Text Field 608
- Text Field 101058
- Text Field 6011
- Text Field 6012
- Text Field 245
- Text Field 246
- Text Field 247
- Text Field 248
- Text Field 249
- Text Field 250
- Text Field 251
- Text Field 252
- Text Field 253
- Text Field 254
- Text Field 255
- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
- Check Box 344 Off
- Check Box 1013 Off
- Check Box 1014 Off
- Check Box 1015 Off
- Check Box 1016 Off
- Check Box 1017 Off
- Check Box 1018 Off
- Check Box 1021 Off
- Check Box 1022 Off
- Check Box 1037 Off
- Check Box 1038 Off
- Text Field 101028
- Text Field 257
- Text Field 258
- Text Field 259
- Text Field 260
- Text Field 261
- Text Field 262
- Text Field 263
- Text Field 264
- Text Field 265
- Text Field 266
- Text Field 267
- Text Field 268
- Text Field 269
- Text Field 270
- Text Field 101030
- Text Field 101031
- Text Field 271
- Text Field 101032
- Text Field 272
- Text Field 273
- Text Field 274
- Text Field 275
- Text Field 276
- Text Field 277
- Text Field 278
- Text Field 279
- Text Field 280
- Text Field 281
- Text Field 282
- Text Field 283
- Text Field 284
- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
- Text Field 288
- Text Field 289
- Text Field 290
- Text Field 291
- Text Field 292
- Text Field 293
- Text Field 294
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- Text Field 296
- Text Field 297
- Text Field 298
- Text Field 299
- Text Field 300
- Text Field 101036
- Text Field 101037
- Text Field 301
- Text Field 101038
- Text Field 302
- Text Field 303
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- Text Field 305
- Text Field 306
- Text Field 307
- Text Field 308
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- Text Field 310
- Text Field 311
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- Text Field 313
- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
- Check Box 349 Off
- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
- Text Field 502
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- Text Field 5010
- Text Field 3012
- Text Field 101040
- Text Field 101042
- Text Field 3013
- Text Field 101044
- Text Field 318
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- Text Field 5011
- Text Field 5012
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- Text Field 5020
- Text Field 321
- Text Field 3014
- Text Field 2030
- Text Field 2031
- Text Field 2032
- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
15
Question 4 ndash continued
What investigations have been carried out If none please state none
Please advise the results of these investigations
What treatment have you received in the past If none please state lsquononersquo
What treatment is currently being given If none please state lsquononersquo
What treatment or investigations are planned If none please state lsquononersquo
On a scale of 0-10 (Where 0 is no pain and 10 is unbearable pain) how bad was your pain at its worst
Using the same scale how bad is your pain now
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of investigations including MRI Xray etc
Helpful hint Treatment could include pills (please advise brand names) surgery chiropractor physiotherapy etc
Approximate date of last symptoms
0
0
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
-
Approximately when was this
-
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Check Box 260 Off
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- Text Field 1077
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- Text Field 144
- Text Field 1022
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- Text Field 1019
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- Text Field 1017
- Text Field 1016
- Text Field 137
- Text Field 1015
- Text Field 1014
- Text Field 136
- Text Field 1011
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- Text Field 135
- Text Field 1010
- Text Field 1013
- Text Field 134
- Text Field 145
- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
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- Text Field 151
- Text Field 152
- Text Field 153
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- Text Field 157
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- Text Field 159
- Check Box 286 Off
- Check Box 287 Off
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- Check Box 289 Off
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- Check Box 291 Off
- Check Box 292 Off
- Check Box 293 Off
- Check Box 294 Off
- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
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- Text Field 339
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- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
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- Text Field 349
- Text Field 350
- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
- Text Field 172
- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
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- Text Field 179
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- Text Field 185
- Text Field 186
- Text Field 187
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- Text Field 189
- Text Field 190
- Text Field 191
- Text Field 192
- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
- Text Field 10107
- Text Field 10109
- Text Field 101010
- Text Field 194
- Text Field 205
- Text Field 195
- Text Field 196
- Text Field 197
- Text Field 198
- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
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- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
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- Check Box 319 Off
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- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
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- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
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- Text Field 101047
- Text Field 101048
- Text Field 221
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- Check Box 335 Off
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- Text Field 101020
- Check Box 339 Off
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- Text Field 2022
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- Text Field 1065
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- Text Field 603
- Text Field 101053
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- Text Field 604
- Text Field 101054
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- Text Field 101029
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- Check Box 343 Off
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- Text Field 101036
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- Check Box 347 Off
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- Text Field 3010
- Text Field 101039
- Text Field 101041
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- Text Field 315
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- Text Field 501
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- Text Field 5010
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
16
Blood pressure
In the last 5 years have you had either of the following
Raised cholesterol or been prescribed treatment for raised cholesterol Yes No
Raised blood pressure or been prescribed treatment for raised blood pressure Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 6
Question 5
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Text Field 352
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- Check Box 246 Off
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- Check Box 272 Off
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- What is your weight 5
- Check Box 274 Off
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- Text Field 1076
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- Check Box 278 Off
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- Text Field 1079
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- Text Field 103
- Check Box 260 Off
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- Text Field 1077
- Text Field 1078
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- Check Box 262 Off
- Check Box 263 Off
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- Text Field 68
- Check Box 282 Off
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- Check Box 298 Off
- Text Field 144
- Text Field 1022
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- Text Field 1021
- Text Field 141
- Text Field 140
- Text Field 1020
- Text Field 139
- Text Field 1019
- Text Field 1018
- Text Field 138
- Text Field 1017
- Text Field 1016
- Text Field 137
- Text Field 1015
- Text Field 1014
- Text Field 136
- Text Field 1011
- Text Field 1012
- Text Field 135
- Text Field 1010
- Text Field 1013
- Text Field 134
- Text Field 145
- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
- Text Field 147
- Text Field 148
- Text Field 149
- Text Field 150
- Text Field 151
- Text Field 152
- Text Field 153
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- Text Field 155
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- Text Field 157
- Text Field 158
- Text Field 159
- Check Box 286 Off
- Check Box 287 Off
- Check Box 288 Off
- Check Box 289 Off
- Check Box 290 Off
- Check Box 291 Off
- Check Box 292 Off
- Check Box 293 Off
- Check Box 294 Off
- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
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- Text Field 338
- Text Field 339
- Text Field 340
- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
- Text Field 348
- Text Field 349
- Text Field 350
- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
- Text Field 172
- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
- Text Field 178
- Text Field 179
- Text Field 180
- Text Field 181
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- Text Field 183
- Text Field 184
- Text Field 185
- Text Field 186
- Text Field 187
- Text Field 188
- Text Field 189
- Text Field 190
- Text Field 191
- Text Field 192
- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
- Text Field 10107
- Text Field 10109
- Text Field 101010
- Text Field 194
- Text Field 205
- Text Field 195
- Text Field 196
- Text Field 197
- Text Field 198
- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
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- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
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- Check Box 323 Off
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- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
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- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
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- Text Field 204
- Text Field 210
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- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
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- Text Field 234
- Check Box 335 Off
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- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
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- Text Field 2022
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- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
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- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
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- Text Field 604
- Text Field 101054
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- Text Field 606
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- Text Field 101058
- Text Field 6011
- Text Field 6012
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1013 Off
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- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
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- Text Field 285
- Text Field 101033
- Text Field 101034
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- Text Field 101035
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- Text Field 101036
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- Check Box 347 Off
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- Check Box 350 Off
- Check Box 351 Off
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- Text Field 3010
- Text Field 101039
- Text Field 101041
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- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
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- Text Field 101040
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- Text Field 318
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- Text Field 5011
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- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
17
Total cholesterol
Question 5 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first raised reading
Approximate monthyear of last reading
What treatment is currently being prescribed
What changes have been made to your treatment in the last year (if none please state none)
How often do you have check ups
What was your last reading
-
-
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 136
- Text Field 1011
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- Text Field 135
- Text Field 1010
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- Text Field 1080
- Text Field 1081
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- Text Field 146
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
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- Text Field 1094
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- Text Field 401
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- Text Field 402
- Text Field 1098
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- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
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- Text Field 10104
- Check Box 301 Off
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- Text Field 176
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- Text Field 193
- Check Box 307 Off
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- Text Field 10105
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- Text Field 194
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- Check Box 309 Off
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- Text Field 101011
- Text Field 101012
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- Text Field 2015
- Text Field 2017
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- Text Field 2021
- Text Field 372
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- Text Field 377
- Check Box 331 Off
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- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
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- Text Field 101047
- Text Field 101048
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- Check Box 335 Off
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- Text Field 101020
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- Text Field 2022
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- Text Field 603
- Text Field 101053
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- Text Field 604
- Text Field 101054
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- Text Field 101029
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- Text Field 101028
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- Text Field 285
- Text Field 101033
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- Text Field 101036
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- Check Box 347 Off
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- Text Field 3010
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- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
18
For reasons of confidentiality you may prefer to send your answers to this question in a sealed envelope or a protected email directly to the Medical Officer marked Private amp Confidential Please see pages 1 and 2 for details on how to return information to us and our confidentiality statement
Have you ever Tested positive for HIV or are you awaiting the result of such a test
In the last 5 years have you Been exposed to the risk of HIV infection (This can be caught through unsafe sex intravenous drug abuse or blood transfusions or surgery undertaken outside the EU)
Tested positive or been treated for any disease which is transmitted sexually (For example chlamydia genital herpes syphilis)
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 7
Question 6
Condition
Date
Postcode
Name and address of any doctor you consulted
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Yes No
- -
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Text Field 1077
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- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 1021
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- Text Field 1020
- Text Field 139
- Text Field 1019
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- Text Field 137
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- Text Field 136
- Text Field 1011
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- Text Field 135
- Text Field 1010
- Text Field 1013
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- Text Field 1080
- Text Field 1081
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- Text Field 146
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- Text Field 159
- Check Box 286 Off
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- Check Box 289 Off
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- Check Box 291 Off
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- Check Box 293 Off
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- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
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- Text Field 338
- Text Field 339
- Text Field 340
- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
- Text Field 348
- Text Field 349
- Text Field 350
- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
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- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
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- Text Field 183
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- Text Field 187
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- Text Field 189
- Text Field 190
- Text Field 191
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
- Text Field 10107
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- Text Field 101010
- Text Field 194
- Text Field 205
- Text Field 195
- Text Field 196
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- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
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- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
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- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
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- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
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- Text Field 215
- Text Field 216
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- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
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- Text Field 226
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- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
- Check Box 1027 Off
- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
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- Text Field 604
- Text Field 101054
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- Text Field 606
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- Text Field 101058
- Text Field 6011
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- Text Field 245
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1013 Off
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- Check Box 1021 Off
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- Check Box 1037 Off
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- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
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- Text Field 285
- Text Field 101033
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- Text Field 286
- Text Field 101035
- Text Field 287
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- Text Field 101036
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- Text Field 314
- Check Box 347 Off
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- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
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- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 318
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- Text Field 5011
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- Text Field 321
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- Text Field 2030
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- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
19
Question 7
Chest pain or irregular heart beat
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
Asthma bronchitis shortness of breath or other disorder of the lungs or respiratory system
Blood disorder or anaemia
Any disorder of the adrenal pituitary or thyroid glands
Any kidney or bladder disorder including renal failure blood protein andor sugar in urine
Any disorder of the digestive system liver stomach pancreas or bowel including gastric or duodenal ulcer colitis or Crohnrsquos disease
Any numbness loss of feeling or tingling in the limbs or face temporary loss of muscle power or visual disturbance
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 8
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Text Field 144
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- Text Field 146
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
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- Text Field 1094
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- Text Field 1097
- Text Field 164
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- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
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- Text Field 101010
- Text Field 194
- Text Field 205
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- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
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- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
- Text Field 214
- Text Field 215
- Text Field 216
- Text Field 217
- Text Field 218
- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
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- Text Field 225
- Text Field 226
- Text Field 227
- Text Field 228
- Text Field 229
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- Text Field 231
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- Text Field 233
- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
- Check Box 1027 Off
- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
- Text Field 237
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- Text Field 604
- Text Field 101054
- Text Field 101056
- Text Field 606
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- Text Field 101058
- Text Field 6011
- Text Field 6012
- Text Field 245
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1013 Off
- Check Box 1014 Off
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- Check Box 1016 Off
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- Check Box 1021 Off
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- Check Box 1037 Off
- Check Box 1038 Off
- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
- Text Field 288
- Text Field 289
- Text Field 290
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- Text Field 300
- Text Field 101036
- Text Field 101037
- Text Field 301
- Text Field 101038
- Text Field 302
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- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
- Check Box 349 Off
- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
- Text Field 3012
- Text Field 101040
- Text Field 101042
- Text Field 3013
- Text Field 101044
- Text Field 318
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- Text Field 5011
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- Text Field 321
- Text Field 3014
- Text Field 2030
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- Text Field 2032
- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
20
Question 7 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of episodes
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Check Box 282 Off
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- Text Field 144
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Text Field 338
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- Text Field 342
- Text Field 343
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- Text Field 345
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
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- Text Field 163
- Text Field 1094
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- Text Field 1095
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- Text Field 164
- Text Field 165
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- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
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- Text Field 101010
- Text Field 194
- Text Field 205
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- Text Field 196
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- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
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- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
- Text Field 214
- Text Field 215
- Text Field 216
- Text Field 217
- Text Field 218
- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
- Text Field 224
- Text Field 225
- Text Field 226
- Text Field 227
- Text Field 228
- Text Field 229
- Text Field 230
- Text Field 231
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- Text Field 233
- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
- Check Box 1027 Off
- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
- Text Field 237
- Text Field 238
- Text Field 239
- Text Field 240
- Text Field 241
- Text Field 242
- Text Field 243
- Text Field 244
- Text Field 604
- Text Field 101054
- Text Field 101056
- Text Field 606
- Text Field 608
- Text Field 101058
- Text Field 6011
- Text Field 6012
- Text Field 245
- Text Field 246
- Text Field 247
- Text Field 248
- Text Field 249
- Text Field 250
- Text Field 251
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- Text Field 253
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- Text Field 255
- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
- Check Box 344 Off
- Check Box 1013 Off
- Check Box 1014 Off
- Check Box 1015 Off
- Check Box 1016 Off
- Check Box 1017 Off
- Check Box 1018 Off
- Check Box 1021 Off
- Check Box 1022 Off
- Check Box 1037 Off
- Check Box 1038 Off
- Text Field 101028
- Text Field 257
- Text Field 258
- Text Field 259
- Text Field 260
- Text Field 261
- Text Field 262
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- Text Field 264
- Text Field 265
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- Text Field 267
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- Text Field 270
- Text Field 101030
- Text Field 101031
- Text Field 271
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- Text Field 272
- Text Field 273
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- Text Field 275
- Text Field 276
- Text Field 277
- Text Field 278
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- Text Field 281
- Text Field 282
- Text Field 283
- Text Field 284
- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
- Text Field 288
- Text Field 289
- Text Field 290
- Text Field 291
- Text Field 292
- Text Field 293
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- Text Field 299
- Text Field 300
- Text Field 101036
- Text Field 101037
- Text Field 301
- Text Field 101038
- Text Field 302
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- Text Field 305
- Text Field 306
- Text Field 307
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- Text Field 311
- Text Field 312
- Text Field 313
- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
- Check Box 349 Off
- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
- Text Field 3012
- Text Field 101040
- Text Field 101042
- Text Field 3013
- Text Field 101044
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- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
21
Question 8
Disorder of the ears or eyes (you can ignore sight problems corrected by glassescontact lenses)
In the last five years have you had or been diagnosed withPlease complete all
YesNo boxes
A lump growth of any kind or mole that has bled become painful changed colour or increased in size
Any breast disorder (males and females)
Any gynaecological disorder ndash including abnormal cervical smears (females only)
Any disorder of the prostate or testes (males only)
Gout or raised uric acid levels
If you have answered lsquoYesrsquo to any of the above please complete the questions below otherwise continue to Question 9
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Helpful hint Males can also develop breast disorders
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
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- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
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- What is your weight 5
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- Check Box 282 Off
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- Text Field 144
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- Text Field 146
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
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- Text Field 1094
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- Text Field 164
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- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
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- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
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- Text Field 101010
- Text Field 194
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- Text Field 199
- Text Field 200
- Check Box 309 Off
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- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
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- Check Box 319 Off
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- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
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- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
- Text Field 214
- Text Field 215
- Text Field 216
- Text Field 217
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- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
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- Text Field 225
- Text Field 226
- Text Field 227
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- Text Field 233
- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
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- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
- Text Field 236
- Text Field 237
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- Text Field 239
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- Text Field 241
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- Text Field 604
- Text Field 101054
- Text Field 101056
- Text Field 606
- Text Field 608
- Text Field 101058
- Text Field 6011
- Text Field 6012
- Text Field 245
- Text Field 246
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1013 Off
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- Check Box 1016 Off
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- Check Box 1021 Off
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- Check Box 1038 Off
- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
- Text Field 288
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- Text Field 290
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- Text Field 101036
- Text Field 101037
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- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
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- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
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- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 509
- Text Field 5010
- Text Field 3012
- Text Field 101040
- Text Field 101042
- Text Field 3013
- Text Field 101044
- Text Field 318
- Text Field 319
- Text Field 320
- Text Field 5011
- Text Field 5012
- Text Field 5013
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- Text Field 321
- Text Field 3014
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- Text Field 2031
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- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
22
Question 8 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
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- Text Field 358
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Check Box 260 Off
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- Text Field 1077
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- Check Box 282 Off
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- Text Field 144
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- Text Field 136
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- Text Field 135
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- Text Field 1080
- Text Field 1081
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- Check Box 286 Off
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- Check Box 297 Off
- Text Field 337
- Text Field 1091
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- Text Field 338
- Text Field 339
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- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
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- Text Field 163
- Text Field 1094
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- Text Field 1097
- Text Field 164
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- Text Field 401
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- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
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- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
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- Check Box 305 Off
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- Text Field 176
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- Text Field 193
- Check Box 307 Off
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- Text Field 10105
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- Text Field 194
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- Check Box 309 Off
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- Check Box 319 Off
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- Check Box 321 Off
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- Check Box 328 Off
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- Check Box 330 Off
- Text Field 101011
- Text Field 101012
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- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
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- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
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- Text Field 211
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- Text Field 101047
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- Check Box 335 Off
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- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
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- Text Field 2022
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- Text Field 2025
- Text Field 2026
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- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
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- Check Box 1025 Off
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- Check Box 1030 Off
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- Check Box 1036 Off
- Text Field 603
- Text Field 101053
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- Text Field 101057
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- Text Field 6010
- Text Field 235
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- Text Field 604
- Text Field 101054
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- Text Field 6011
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- Text Field 245
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
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- Text Field 101036
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- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
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- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
- Text Field 3012
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- Text Field 318
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- Text Field 5011
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- Text Field 321
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
23
Question 9
Have you consulted a doctor in the last 5 years for any condition(s) other than those already disclosed Yes No
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you have answered lsquoYesrsquo to the above please complete the questions below otherwise continue to Question 10
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 352
- Check Box 2 Off
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- Text Field 358
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- Text Field 1082
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- Text Field 73
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- What is your weight 5
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- Text Field 1076
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- Check Box 278 Off
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- Text Field 1079
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- Check Box 260 Off
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- Text Field 1077
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- Text Field 37
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- Check Box 262 Off
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- Check Box 282 Off
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- Text Field 144
- Text Field 1022
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- Text Field 1021
- Text Field 141
- Text Field 140
- Text Field 1020
- Text Field 139
- Text Field 1019
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- Text Field 138
- Text Field 1017
- Text Field 1016
- Text Field 137
- Text Field 1015
- Text Field 1014
- Text Field 136
- Text Field 1011
- Text Field 1012
- Text Field 135
- Text Field 1010
- Text Field 1013
- Text Field 134
- Text Field 145
- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
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- Text Field 150
- Text Field 151
- Text Field 152
- Text Field 153
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- Text Field 157
- Text Field 158
- Text Field 159
- Check Box 286 Off
- Check Box 287 Off
- Check Box 288 Off
- Check Box 289 Off
- Check Box 290 Off
- Check Box 291 Off
- Check Box 292 Off
- Check Box 293 Off
- Check Box 294 Off
- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
- Text Field 1093
- Text Field 338
- Text Field 339
- Text Field 340
- Text Field 341
- Text Field 342
- Text Field 343
- Text Field 344
- Text Field 345
- Text Field 346
- Text Field 347
- Text Field 348
- Text Field 349
- Text Field 350
- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
- Text Field 161
- Text Field 162
- Text Field 163
- Text Field 1094
- Text Field 1096
- Text Field 1095
- Text Field 1097
- Text Field 164
- Text Field 165
- Text Field 166
- Text Field 167
- Text Field 168
- Text Field 169
- Text Field 170
- Text Field 171
- Text Field 172
- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
- Text Field 178
- Text Field 179
- Text Field 180
- Text Field 181
- Text Field 182
- Text Field 183
- Text Field 184
- Text Field 185
- Text Field 186
- Text Field 187
- Text Field 188
- Text Field 189
- Text Field 190
- Text Field 191
- Text Field 192
- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
- Text Field 10106
- Text Field 10107
- Text Field 10109
- Text Field 101010
- Text Field 194
- Text Field 205
- Text Field 195
- Text Field 196
- Text Field 197
- Text Field 198
- Text Field 199
- Text Field 200
- Check Box 309 Off
- Check Box 310 Off
- Check Box 311 Off
- Check Box 312 Off
- Check Box 313 Off
- Check Box 314 Off
- Check Box 315 Off
- Check Box 316 Off
- Check Box 317 Off
- Check Box 318 Off
- Check Box 319 Off
- Check Box 320 Off
- Check Box 321 Off
- Check Box 322 Off
- Check Box 323 Off
- Check Box 324 Off
- Check Box 325 Off
- Check Box 326 Off
- Check Box 327 Off
- Check Box 328 Off
- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
- Text Field 101013
- Text Field 101014
- Text Field 101015
- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
- Text Field 374
- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
- Text Field 202
- Text Field 203
- Text Field 204
- Text Field 210
- Text Field 211
- Text Field 212
- Text Field 213
- Text Field 214
- Text Field 215
- Text Field 216
- Text Field 217
- Text Field 218
- Text Field 219
- Text Field 220
- Text Field 101047
- Text Field 101048
- Text Field 221
- Text Field 222
- Text Field 223
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- Text Field 225
- Text Field 226
- Text Field 227
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- Text Field 229
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- Text Field 231
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- Text Field 233
- Text Field 234
- Check Box 335 Off
- Check Box 336 Off
- Check Box 337 Off
- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
- Text Field 2023
- Text Field 2024
- Text Field 2025
- Text Field 2026
- Text Field 2027
- Text Field 2028
- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
- Check Box 342 Off
- Check Box 1025 Off
- Check Box 1026 Off
- Check Box 1027 Off
- Check Box 1028 Off
- Check Box 1029 Off
- Check Box 1030 Off
- Check Box 1031 Off
- Check Box 1032 Off
- Check Box 1033 Off
- Check Box 1034 Off
- Check Box 1035 Off
- Check Box 1036 Off
- Text Field 603
- Text Field 101053
- Text Field 101055
- Text Field 605
- Text Field 607
- Text Field 101057
- Text Field 609
- Text Field 6010
- Text Field 235
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- Text Field 604
- Text Field 101054
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- Text Field 606
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- Text Field 101058
- Text Field 6011
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- Text Field 245
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1013 Off
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- Check Box 1021 Off
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- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
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- Text Field 101036
- Text Field 101037
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- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
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- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
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- Text Field 318
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- Text Field 5011
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- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
24
Question 9 ndash continued
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
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- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
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- What is your weight 5
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- Check Box 286 Off
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- Text Field 337
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- Check Box 299 Off
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- Text Field 160
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- Text Field 1094
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- Text Field 401
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- Text Field 1098
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- Text Field 1099
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- Check Box 301 Off
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- Text Field 176
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- Check Box 307 Off
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- Text Field 10105
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- Text Field 101011
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- Text Field 2015
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- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
25
Question 10
Do you have any other medical issues or symptoms not already disclosed
Are you taking any other prescribed medication
Are you intending to see a medical professional
Yes
Yes
Yes
No
No
No
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
If you have answered lsquoYesrsquo to any of the above please complete the questions below
If you have any further information relating to this question please use the space provided on the following page
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Text Field 144
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- Check Box 286 Off
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- Text Field 337
- Text Field 1091
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- Text Field 351
- Check Box 299 Off
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- Text Field 160
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- Text Field 1094
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- Text Field 164
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- Text Field 401
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- Text Field 1098
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- Text Field 1099
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- Check Box 301 Off
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- Text Field 176
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- Check Box 307 Off
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- Text Field 10105
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- Text Field 194
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- Check Box 309 Off
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- Text Field 101011
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- Text Field 2015
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- Check Box 331 Off
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- Text Field 101045
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- Text Field 101020
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- Text Field 603
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- Text Field 101028
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- Check Box 347 Off
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- Text Field 3010
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- Radio Button 2 Off
Health DeclarationPart 5 ndash Medical information
26
Question 10 ndash continued
Helpful hint We may be able to make a quicker decision if you attach copies of any correspondence showing results of any investigations
If you need further space please continue on a separate piece of paper
Condition andor type
Investigations conducted
Current treatment (if none please state lsquononersquo)
Number of days off work (if none please state lsquononersquo)
Results of these investigations
Number of episodes
Approximate monthyear of first symptoms
-
Approximate monthyear of last symptoms
-
Please now read pages 27 28 29 and 30 and then you need to sign and date lsquoYour Declaration and Consentrsquo on page 30
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Estimated total duration of all visits in the next 12 months 3
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- Estimated total duration of all visits in the next 12 months 4
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- Estimated total duration of all visits in the next 12 months 5
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- Estimated total duration of all visits in the next 12 months 6
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- What is your weight 5
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- Check Box 307 Off
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- Radio Button 2 Off
Health DeclarationData Protection Notice
27
Canada Life Limited (referred to as lsquoCanada Lifersquo lsquowersquo lsquousrsquo or lsquoourrsquo in this DPN) takes its privacy obligations very seriously Any personal data provided to us as data controller by a policyholder joint policyholder employer policyholder trustee insured person beneficiary claimant or member (referred to as lsquoyoursquo or lsquoyourrsquo in this DPN) will be treated in accordance with the Data Protection Act 2018(DPA)
Using Personal DataWe use personal data to undertake activities relating to the setting up administration and renewal of our policies products and services This includes processing applications and handling any claims For the majority of our business we will rely on the performance of our contractual arrangements with you as the legal basis for processing
We do not use policyholder member or beneficiary personal data for marketing purposes and we do not make your personal data available to third parties for the purpose of direct marketing
The nature of our business is to provide investments life and pensions cover critical illness income protection and employer related group products To do this we need to use the personal data provided to carry out analysis of actuarial risks (risks of gains or losses) mortality and morbidity risks and pricing This will be carried out in accordance with the Institute amp Faculty of Actuariesrsquo data handling protocols
We use underwriting software to process some applications and quotations which will use an element of automated decision making
Exceptionally we may rely on our legitimate interests to process your personal data When we do we will demonstrate compelling legitimate grounds for doing so
For employer-related group insurance products the DPA permits appropriate information about employees to be provided by an employer to an insurer without individual consent (including details of long-term absentees current and previous claimants and medical underwriting decisions)
For employer-related group products the DPA permits that members may individually withdraw their consent in those instances Canada Life will be unable to provide cover for that individual
When medically underwriting or assessing a claim we will obtain consent from the employee
Sharing personal dataWe share personal data only on the basis of the purposes for which it was collected This notice is intended to illustrate the instances where data may be shared However we will share your data only for the limited and compatible purposes for which it was originally obtained
bull with other Canada Life group companies including those outside the European Economic Area (EEA)
bull with any of our service providers reinsurers and or regulators
bull with other insurers and government agencies including without limitation Her Majestyrsquos Revenue and Customs (HMRC) Department of Work and Pensions (DWP)
bull in order to prevent detect or investigate financial crime including fraud or other criminal activity we may share your data with other companies (including private investigators) organisations (including fraud prevention agencies and databases) public bodies (including the police) and associations and credit reference agencies
bull we will not share your medical information with anyone other than yourself without your consent except as described in the next bullet point This includes your employer spouse other relatives friends or your legal or professional adviser In some circumstances it may be appropriate to advise your employer about your medical information for example to recommend alternative supportive therapy However we will seek your consent in such circumstances
bull for employer-related products and services only some medical information related to underwriting decisions and non-medical information about you necessary for lawful policy and claim administration purposes will be shared with your employer
bull we will not share non-medical information concerning you with your spouse other relatives friends or your legal or professional adviser unless you provide your consent to us in writing
bull for insurance related products with your own doctor or relevant medical professionals andor
bull in any circumstances if permitted or required to do so by law or if we have your consent to do so
International TransfersGiven the global nature of our business we use third party suppliers and outsourced services (including cloud-based services) which can require transfers of personal data outside of the EEA In doing so we ensure there are contractual arrangements in place with those organisations who have organisational and technical measures to protect your personal data
Retention of your personal dataWe will keep your personal data only for so long as is necessary and for the purpose for which it was originally collected In particular for so long as there is any possibility that either you or we may wish to bring a legal claim under this insurance or where we are required to keep your personal data due to legal or regulatory reasons
Post Brexit ndash UK departure from the European UnionOn 31 January 2020 the UK left the European Union (lsquoEUrsquo) ceasing to be a member EU law requires that all entities processing the data of EU citizens that are not established in the EU designate in writing a Representative in the EU to be addressed in addition to or instead of that entity by EU citizens on all issues related to data processing In order to meet our requirements each Canada Life entity listed above which processes the personal data of EU citizens has designated Canada Life Irish Holding Company Limited an Irish registered entity within the Canada Life group as its Representative The Representative may also be called upon to cooperate with competent supervisory authorities with regard to ensuring compliance with the General Data Protection Regulation (lsquoGDPRrsquo)
Contractual clauses in place between Canada Life and its group entities and external suppliers are compliant with the GDPR which ensures that personal data provided to Canada Life is processed in accordance with our instructions and the requirements of the GDPR Canada Life will continue to follow and apply all appropriate data protection legislation including that provided by the UK Government and the Information Commissionerrsquos Office (ICO) with regards to data protection
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
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- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
- Check Box 264 Off
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- Check Box 272 Off
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- Text Field 73
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- What is your weight 5
- Check Box 274 Off
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- Text Field 1076
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- Check Box 278 Off
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- Check Box 260 Off
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- Text Field 1077
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- Check Box 262 Off
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- Check Box 282 Off
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- Check Box 298 Off
- Text Field 144
- Text Field 1022
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- Text Field 1021
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- Text Field 1020
- Text Field 139
- Text Field 1019
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- Text Field 1017
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- Text Field 1011
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- Text Field 1013
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- Text Field 1080
- Text Field 1081
- Text Field 1090
- Text Field 146
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- Text Field 159
- Check Box 286 Off
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- Check Box 291 Off
- Check Box 292 Off
- Check Box 293 Off
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- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
- Text Field 1092
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- Text Field 338
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
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- Text Field 1094
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- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
- Text Field 174
- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
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- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
- Text Field 177
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- Text Field 193
- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
- Text Field 10108
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- Text Field 101010
- Text Field 194
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- Text Field 200
- Check Box 309 Off
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- Check Box 329 Off
- Check Box 330 Off
- Text Field 101011
- Text Field 101012
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- Text Field 2015
- Text Field 2017
- Text Field 2018
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- Text Field 2021
- Text Field 372
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- Text Field 377
- Check Box 331 Off
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- Text Field 101045
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- Text Field 101047
- Text Field 101048
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- Check Box 335 Off
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- Text Field 101020
- Check Box 339 Off
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- Text Field 2022
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- Text Field 1065
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- Check Box 341 Off
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- Text Field 603
- Text Field 101053
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- Text Field 604
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Text Field 101028
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- Text Field 101030
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- Check Box 345 Off
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- Text Field 285
- Text Field 101033
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- Text Field 101035
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- Text Field 101036
- Text Field 101037
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- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
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- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
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- Text Field 101043
- Text Field 315
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- Text Field 501
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- Text Field 5010
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- Text Field 101042
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- Text Field 101044
- Text Field 318
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- Text Field 5011
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- Text Field 321
- Text Field 3014
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- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationData Protection Notice
28
YOUR RIGHTS AND CONTACT DETAILS OF THE INFORMATION COMMISSIONERrsquoS OFFICE (ICO) You may have the right to require us to
bull provide you with further details on the use we make of your personal data or your special categories of data
bull provide you with a copy of the personal data that you have provided to us or which we hold
bull update any inaccuracies in the personal data we hold
bull delete any special category of data or personal data for which we no longer have lawful grounds to use
bull cease processing of your personal data that is based on consent by withdrawing your consent to that particular processing
bull cease any processing based on legitimate interests grounds unless our reasons for undertaking that processing outweigh any prejudice to your data protection rights and
bull restrict how we use your personal data whilst a complaint is being investigated
In certain circumstances we may need to restrict the rights listed above in order to safeguard the public interest (eg the prevention or detection of crime) our interests (eg the maintenance of our legal responsibilities) and for the performance of our contract with an employer who is the policyholder for employer-related products and services
Data Protection Officer (DPO)If you have any questions or complaints in relation to our use of your personal data you should first contact our DPO on the details below
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BAor by email at dpocanadalifecouk
In the unlikely event that you are dissatisfied with our response you have the right to take the matter up with the Information Commissionerrsquos Office (ICO) whose address is Information Commissionerrsquos Office Wycliffe House Water Lane Wilmslow Cheshire SK9 5AF
The full version of our DPN can be found on our website wwwcanadalifecouk or is available upon request by calling 0345 223 8000
This DPN is dated 1st January 2021 Any future updates will be made available as described above
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
- Check Box 397 Off
- Check Box 402 Off
- Check Box 403 Off
- Check Box 404 Off
- Check Box 405 Off
- Check Box 398 Off
- Check Box 399 Off
- Check Box 400 Off
- Check Box 401 Off
- Text Field 352
- Check Box 2 Off
- Check Box 3 Off
- Text Field 358
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- Text Field 7
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- Text Field 14
- Check Box 246 Off
- Check Box 247 Off
- Text Field 1071
- Text Field 1072
- Text Field 1073
- Text Field 10110
- Text Field 368
- Text Field 369
- Text Field 370
- Text Field 371
- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
- Check Box 264 Off
- Check Box 265 Off
- Check Box 266 Off
- Check Box 267 Off
- Check Box 268 Off
- Check Box 269 Off
- Check Box 270 Off
- Check Box 271 Off
- Text Field 1074
- Text Field 1075
- Text Field 69
- Text Field 378
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- Text Field 1070
- Check Box 272 Off
- Check Box 273 Off
- Text Field 73
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- Text Field 79
- Text Field 80
- Text Field 81
- What is your weight 5
- Check Box 274 Off
- Check Box 275 Off
- Check Box 276 Off
- Check Box 277 Off
- Text Field 1076
- Text Field 82
- Text Field 83
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- Check Box 278 Off
- Check Box 279 Off
- Text Field 93
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- Text Field 1079
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- Text Field 103
- Check Box 260 Off
- Check Box 261 Off
- Text Field 1077
- Text Field 1078
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- Text Field 38
- Check Box 262 Off
- Check Box 263 Off
- Text Field 39
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- Check Box 282 Off
- Check Box 283 Off
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- Check Box 285 Off
- Check Box 298 Off
- Text Field 144
- Text Field 1022
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- Text Field 1021
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- Text Field 1020
- Text Field 139
- Text Field 1019
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- Text Field 1081
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- Text Field 159
- Check Box 286 Off
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- Check Box 292 Off
- Check Box 293 Off
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- Check Box 295 Off
- Check Box 296 Off
- Check Box 297 Off
- Text Field 337
- Text Field 1091
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- Text Field 351
- Check Box 299 Off
- Check Box 300 Off
- Text Field 160
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- Text Field 1094
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- Text Field 401
- Text Field 173
- Text Field 402
- Text Field 1098
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- Text Field 175
- Text Field 1099
- Text Field 10100
- Text Field 10101
- Text Field 10103
- Text Field 10102
- Text Field 10104
- Check Box 301 Off
- Check Box 302 Off
- Check Box 303 Off
- Check Box 304 Off
- Check Box 305 Off
- Check Box 306 Off
- Text Field 176
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- Check Box 307 Off
- Check Box 308 Off
- Text Field 10105
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- Check Box 330 Off
- Text Field 101011
- Text Field 101012
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- Text Field 2015
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- Text Field 101045
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- Text Field 101020
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- Radio Button 2 Off
Health DeclarationAccess to medical reports ndash your rights
29
Your rights under the Act are as followsbull You do not need to give your permission but
if you do not we may not be able to assess this claim in respect of you
bull This does not prevent you from applying personally to other companies for insurance
bull You can ask to see the report before the doctor returns it to us If this is the case we will tell the doctor to keep the report for 21 days so that you can arrange to see it If you have not made arrangements to see the report within this time your doctor will send the report to us
bull If you choose not to see the report at this stage you may ask the doctor for a copy within six months of it being sent to us We can send a copy of the report to your doctor if you ask to see it at a later date
bull If you think that any part of the report is not correct or is misleading you may ask the doctor to amend it If your doctor refuses to make the amendments you may ask him or her to attach a statement outlining your views which will then accompany the report
bull Your doctor can withhold access to the report if he or she feels that it would cause physical or mental harm to you or others
Got a question If you have any questions about your rights under the act or questions relating to the process of getting assessing or storing medical information please write to the Data Protection Officer or the Head of Privacy and Data Protection at Canada Life
Canada Life Limited Canada Life Place Potters Bar Hertfordshire EN6 5BA or by email at dpocanadalifecouk
We may need to get medical reports before providing you with the proposed level of cover Before we can ask any doctor that you have consulted to fill in a report we need your permission under the Access to Medical Reports Act 1988 or the Access to Personal Files and Medical Reports (Northern Ireland) Order 1991
Your current healthbull Any care medication or treatment you are currently receiving
bull The results of referrals or tests you are waiting for
bull Any time off work in the last three years
Your past healthbull Details of any relevant illness trauma or referrals for specialist advice or
treatment hospital admissions consultations with your GP or any other medical adviser therapist or counsellor in particular whether you have a history of
ndash malignancy (cancer) cardiovascular (heart) disease diabetes and degenerative (gradually worsening) diseases
ndash musculoskeletal disease or injury for example arthritis rheumatism back problems or any other disorder of the joints or muscles
ndash anxiety depression neurosis (such as phobias obsessions etc) psychosis (a mental disorder where you lose contact with reality) stress or fatigue suicidal thoughts or attempts at suicide or
ndash conditions related to drug or alcohol misuse or smoking or chewing tobacco
bull Details of any biopsies blood tests electrocardiograms (heart tests) height weight if measured in the last two years urinalyses (tests on urine) x-rays or other investigations
bull Any blood pressure readings in the last three years
bull Any history of disease among your parents or brothers or sisters that you have told your doctor about
We would not ask your doctor to reveal information aboutbull negative tests for HIV hepatitis B or C
bull any sexually-transmitted diseases unless there could be long-term effects on your health or
bull predictive genetic test results unless there is a favourable test result which shows that you have not inherited a condition your family suffers from
The information you and your doctor provide about your health may result in usbull providing cover for you at normal rates
bull imposing special rates for the level of cover being underwritten
bull imposing special terms eg exclusions to the level of cover being underwritten
bull refusing to provide the level of cover being underwritten
bull using the information to assess a claim
The medical report your doctor fills in asks about the following
2
3
1
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
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- Text Field 371
- Country 3
- City or region of this country 3
- Estimated total duration of all visits in the next 12 months 3
- Country 4
- City or region of this country 4
- Estimated total duration of all visits in the next 12 months 4
- Country 5
- City or region of this country 5
- Estimated total duration of all visits in the next 12 months 5
- Country 6
- City or region of this country 6
- Estimated total duration of all visits in the next 12 months 6
- Country 8
- City or region of this country 8
- Estimated total duration of all visits in the next 12 months 8
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- What is your weight 5
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- Check Box 286 Off
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- Text Field 337
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- Check Box 299 Off
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- Text Field 160
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- Text Field 1094
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- Text Field 1099
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- Check Box 301 Off
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- Text Field 176
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- Check Box 307 Off
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- Check Box 309 Off
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- Check Box 330 Off
- Text Field 101011
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- Text Field 2015
- Text Field 2017
- Text Field 2018
- Text Field 2019
- Text Field 2020
- Text Field 2021
- Text Field 372
- Text Field 373
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- Text Field 375
- Text Field 376
- Text Field 377
- Check Box 331 Off
- Check Box 332 Off
- Check Box 333 Off
- Check Box 334 Off
- Text Field 101045
- Text Field 101046
- Text Field 201
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- Text Field 101047
- Text Field 101048
- Text Field 221
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- Text Field 234
- Check Box 335 Off
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- Check Box 338 Off
- Text Field 101020
- Check Box 339 Off
- Check Box 340 Off
- Text Field 2022
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- Text Field 2025
- Text Field 2026
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- Text Field 2029
- Text Field 1065
- Text Field 1066
- Text Field 1067
- Check Box 341 Off
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- Check Box 1036 Off
- Text Field 603
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- Text Field 604
- Text Field 101054
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- Text Field 6011
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- Text Field 101029
- Text Field 101027
- Text Field 256
- Check Box 343 Off
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- Check Box 1038 Off
- Text Field 101028
- Text Field 257
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- Text Field 101030
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- Text Field 284
- Check Box 345 Off
- Check Box 346 Off
- Text Field 285
- Text Field 101033
- Text Field 101034
- Text Field 286
- Text Field 101035
- Text Field 287
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- Text Field 300
- Text Field 101036
- Text Field 101037
- Text Field 301
- Text Field 101038
- Text Field 302
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- Text Field 313
- Text Field 314
- Check Box 347 Off
- Check Box 348 Off
- Check Box 349 Off
- Check Box 350 Off
- Check Box 351 Off
- Check Box 352 Off
- Text Field 3010
- Text Field 101039
- Text Field 101041
- Text Field 3011
- Text Field 101043
- Text Field 315
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- Text Field 501
- Text Field 502
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- Text Field 5010
- Text Field 3012
- Text Field 101040
- Text Field 101042
- Text Field 3013
- Text Field 101044
- Text Field 318
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- Text Field 5011
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- Text Field 5018
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- Text Field 5020
- Text Field 321
- Text Field 3014
- Text Field 2030
- Text Field 2031
- Text Field 2032
- Text Field 2033
- Text Field 2035
- Text Field 2037
- Radio Button 2 Off
Health DeclarationDeclaration and consent
30
Print full name
Date (day month year)
ImportantYou should provide the answers on this form personally If the answers are filled in by anyone else then they must be read over and agreed by you before the declaration is signed Any amendments or alterations should be completed and initialled by you
I confirm that I have answered the questions in this form honestly and have taken reasonable care to ensure those answers are correct
I confirm that in the period before the acceptance of this cover I will inform Canada Life of any matter or fact that would make answers to the questions in this form incomplete incorrect or untrue
I agree to Canada Lifebull Obtaining relevant information about me including without limitation my physical or mental health lifestyle occupation duties and potentially hazardous activities from
ndash any medical professional that has attended me (either obtained by Canada Life or its 3rd party service provider)
ndash any medical examination or tests that Canada Life arranges
ndash any telephone interview Canada Life arranges
ndash my employer or their agent
ndash other insurers who I have applied to or may cover me for life critical illness sickness disability accident or private medical insurance
bull Using and sharing my personal data as set out in the Data Protection Notice included on this form
Please ensure you tick one of the following boxes in respect of your rights under the Access to Medical Reports Act 1988 If you wish to see the report you have 21 days to make arrangements to visit your doctor
If the person for whom the benefit is being insured is unable to sign the consent please call Canada Life on 0117 916 4415
I DO NOT want to see any report from my doctor before it is sent to Canada Life
I DO want to see any report from my doctor before it is sent to Canada Life
In most cases we can make a decision just with the information you provide Occasionally we may have further requirements
This could include us
bull contacting you for further details
bull requesting a report from your doctor or
bull asking you to attend a medical examinationtests usually via a third party
Communication of progress updates and our final decision letter will be via your employer or their Financial Adviser
If you have any further questions please feel free to contact our Customer Service Team on 0345 223 8000
Our forms are available to download from our website wwwcanadalifecoukgroup Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER Telephone 0345 223 8000
Canada Life Limited registered in England no 973271 Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA CLFIS (UK) Limited registered in England no 04356028 is an associate company of Canada Life Limited Registered Office Canada Life Place Potters Bar Hertfordshire EN6 5BA Canada Life Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority
GRP108ndash 321R(B)
What happens next
Signature
Please provide an original signature
- - 2 0
Please mark as lsquoPrivate and Confidentialrsquo
How to return your form
By emailmedicalunderwritingcanadalifecouk
By postMedical Underwriting Team Canada Life Limited 3 Rivergate Temple Quay Bristol BS1 6ER
Scanned or photographed images of the completed form and any medical information can be emailed
- Check Box 396 Off
- Check Box 397 Off
- Check Box 402 Off
- Check Box 403 Off
- Check Box 404 Off
- Check Box 405 Off
- Check Box 398 Off
- Check Box 399 Off
- Check Box 400 Off
- Check Box 401 Off
- Text Field 352
- Check Box 2 Off
- Check Box 3 Off
- Text Field 358
- Text Field 357
- Text Field 353
- Text Field 354
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