9 Declaration (for the individual completing this form)

I certify that the information in this application is true and complete, to the best of my knowledge.

Name of person completing this form

I certify that the information in this application is true and complete, to the best of my knowledge.

If different from section 2 above, please also provide contact information.

Yes No

The information in this statement will be kept in a group life, health or disability benefits file with Manulife and might be accessible by the plan member or third parties to whom access has been granted or those authorized by law. By providing the information you consent to such unedited release of any information contained herein.

Submit