Declaration and Authorization

I (the Applicant) hereby apply for insurance to The Manufacturers Life Insurance Company (Manulife).

I declare that the statements contained in this application, including the health declaration originally attached hereto, are true and complete. I understand that this application, together with any other forms signed by me in connection with this application, forms the basis for any certificate or additional coverage issued hereunder. The person to be insured understands that any material misrepresentation, including misstatement of smoker status, shall render the insurance voidable at the instance of the insurer. I understand that exclusions and limitations apply to the coverage applied for. Suicide within the first two years is a risk not covered. Relative to the insurance applied for, I, the person to be insured, or parent/​guardian if the person to be insured is a minor child, hereby authorize any licensed physician, medical practitioner, hospital, pharmacy, clinic or other medically related facility, insurance company, MIB, Inc., the group policy administrator, the insurance plan sponsor, any investigative and security agency, any agent, broker or market intermediary, any government agency or other organization or person that has any records or knowledge of me or my health or the health of any member of my family to be insured pursuant to this application to provide to Manulife or its reinsurers any such information for the purpose of this application and contract and any subsequent claim. I authorize Manulife to consult its existing files for this purpose.

I authorize Manulife, its subsidiaries, affiliates and agents to use the information in this application and its existing files to offer me their products or services. I understand that my consent to the use of such information to offer me products or services is optional, and that if I wish to discontinue such use, I may write to Manulife at the address shown on this document. A photocopy or faxed copy of this authorization shall be as valid as the original.

I acknowledge receipt of and confirm my agreement with the Declaration and Authorization, Information about MIB, Inc. and Personal Information Statement.

I (the Applicant) hereby designate the individual(s) named as beneficiary(ies) to receive the proceeds payable upon my death.
I declare that I have been made aware of the reasons why the health information is needed and the risks and benefits to the individual of consenting or refusing to consent. I understand that this consent may be revoked at any time and that, if as a result of such revocation the insurer is unable to obtain proof of claim, this may result in claims not being paid.

I acknowledge that the insurer may request a medical examination, urinalysis or tests such as a general blood profile (including blood test for HIV) which will be made at no expense to me. I further acknowledge that results of any positive infectious disease tests will be reported to the appropriate provincial or territorial health department if required by law, and that based on my health information, Manulife may offer insurance on an alternative basis or may decline to offer coverage.

I acknowledge that coverage will take effect on the date the properly completed application (including my properly completed health declaration) and the first premium are received by Manulife, subject to the approval of the Company’s underwriters. If I am approved, I will receive a certificate specifying the coverage provided and outlining the main policy provisions. If I am not insurable, a full refund of the premiums will be made.

By providing your email address herein, you consent to us providing information or documents to you in respect of this application or policy, as applicable, in electronic form.

Personal Information Statement

In this Statement, ​“you” and ​“your” refer to the policyowner or holder of rights under the contract , the insured and the parent or guardian of any child named as insured who is under the legal age for providing consent. ​“We”, ​“us”, ​“our” and ​“the Company” refer to The Manufacturers Life Insurance Company and our affiliated companies and subsidiaries.

Updates to this Statement and further information about our privacy practices are posted to www​.man​ulife​.ca.
We collect, use, verify and disclose your personal information for identified purposes, and only with your consent, or as permitted or required by law. By selecting submit or by signing the application, you give your consent for us to collect, use, and disclose your personal information, as set out in this Personal Information Statement. Any alterations to the consent must be agreed to in writing by the Company.

What personal information do we collect?

Depending on the product you have applied for, we collect specific personal information about you such as:

• Identifying information such as your name, address, telephone number(s), email address, your date of birth, or driver’s license
• Medical information that any organization or person has about you
• A personal investigation, financial information, credit bureau report and/​or a consumer report from other organizations, person or source that has any information or records about you
• Information about how you use our products and services, and information about your preferences, demographics, and interests
• Other personal information we may require to administer our business relationship with you

We use fair and lawful means to collect your personal information.

Where do we collect your personal information from?

• Your completed applications and forms
• Other interactions between you and the Company,
• Other sources, such as:
  • Your advisor or authorized representative(s)
  • Third parties with whom we deal in issuing and administering your policy now, and in the future
  • Public sources, such as government agencies, and internet sites

What do we use your personal information for?

We will use your personal information to:

• help us properly administer the products and services that we provide and to manage our relationship with you
• Confirm your identity and the accuracy of the information you provide
• Evaluate your application, and issue and administer the rights under the policy
• Comply with legal and regulatory requirements
• Understand more about you and how you like to do business with us
• Analyze data to help us understand our customers better so we can improve the products and services we provide
• Determine your eligibility for, and provide you with details of, other products or services that may be of interest to you

Who do we disclose your information to?

• Persons, financial institutions and other parties with whom we deal in issuing and administering your policy now, and in the future
• Authorized employees, agents and representatives
• Your advisor and any agency which has entered into an agreement with us and has supervisory authority, directly or indirectly, over your advisor, and their employees
• Any person or organization to whom you gave consent
• People who are legally authorized to view your personal information
• Service providers who require this information to perform their services for us (for example data processing, programming, data storage, market research, printing and distribution services, paramedical and investigative agencies)
• Your medical doctor
• Public health authorities as required, if laboratory tests performed on our behalf show that you have tested positive for infectious disease
  

The above mentioned people, organizations and service providers are both within Canada and jurisdictions outside Canada, and would therefore be subject to the laws of those jurisdictions.

Where personal information is provided to our service providers, we require them to protect the information in a manner that is consistent with our privacy policies and practices.

How long do we keep your information?

The longer of:

• the time period required by law and by guidelines set for the financial services industry, and
• the time period required to administer the products and services we provide.

Withdrawing your consent

You may withdraw your consent for us to use your personal information to provide you with other service or product offerings, excluding those mailed with your statements.

You may not withdraw your consent for us to collect, use, retain or disclose personal information we need to issue or administer the policy unless federal or provincial laws give you this right. If you do so, a policy may not be issued and benefits will not be payable under the contract or we may treat your withdrawal of consent as a request to terminate the contract.

If you wish to withdraw your consent, phone our customer care centre at 1 – 888-MANULIFE (626−8543), or 1 – 888-MANUVIE (626−8843) in Quebec, or write to the Privacy Officer at the address below.

Accuracy and Access

You will notify us of any change to your contact information. You have the right to access and verify your personal information maintained in our files, and to request any factually inaccurate personal information be corrected, if appropriate. If you have a question, a concern, wish to receive more information about parties who have access to your information or about our privacy policies and procedures, and/​or wish to review your personal information in our files or correct any inaccuracies, you may send a written request to:
Privacy Officer Manulife 500 King Street N. Waterloo, ON N2J 4C6

Privacy_​office_​canadian_​division@​manulife.​com
Please note the security of email communication cannot be guaranteed. Do not send us information of a private or confidential nature by email. By contacting us via email you are authorizing us to communicate with you by email.