5/14/2026, 12:53 PM EDT TO: +16045227206 FROM: 18335201506 OPIFINY PAGE 1/5

canada Life

opifiny REQUEST
ug es| FAXED 06/08/26 cr

Invoice/Prepayment Required

FAX COVER PAGE

Attn: Dr. G. Ademiluyi EP asians
Medical Information Request

Group Disability

On Behalf of Patient:

Mark Holand

1978-09-04

Reference ID #: 130684485

Per your request, please complete the attached medical history questions Sent From:
from your patient's insurance company. Canada Life
Group Disability

To access your patient's signed consent to release medical information,
please see the last page of this request package.

Please include this cover page when faxing the completed

information back Sent To:

Dr. G. Ademiluyi
ns ee ee , 420 Columbia Street

Fax Completed Requests to: ' New Westminster

(833) 520-1506 gee

Or, complete this request online and get paid quickly. Please visit:
https://login.opifiny.com

Code: SNCRDMQ

First Name:

Last Name: Dr. G. Ademiluyi

Questions? Please call Opifiny* Customer service: Generated by opifiny | Request # QHBZWWZTH | May 14, 2026
By phone at 1-833-OP/FINY or by email at support@opifiny.com Page 1/5

O-FRM-FFCOVR-EN-1 | OPIFINY ID: QHBZWWZTH