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During the last 12 months What was the amount of weight change Was this a gain or a loss Postal code If Yes please answer the following Reason Name of personal physician last first and middle initial Address of personal physician number street suite Physician s phone number 3 Spousal statement Spouse s name last first and middle initial The Manufacturers Life Insurance Company Page 1 of 4 GL0004E 05/2007 4 Dependant information Please provide the.

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