INDIVIDUAL AD&D/PERSONAL ACCIDENT APPLICATION FORM TO BE COMPLETED BY PROPOSED INSURED PERSON. PLEASE ANSWER ALL QUESTIONS. Proposed Insured Person * First Name Last Name Citizenship Address Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Sex Height Weight Profession or Occupation * Nature of Duties Employer’s Name Employer’s Address Average annual earnings, past three years, derived from your profession excluding income from other sources Estimated earnings next twelve months BENEFITS BEING APPLIED FOR Accidental death only (state CDN or US dollars): $ Accidental death and dismemberment (state CDN or US dollars): $ Beneficiary if other than the Proposed Insured Person’s Estate Relationship to the Proposed Insured Person BROKER INFORMATION Broker/Agent/Consultant Contact Name and Telephone Number MEDICAL QUESTIONNAIRE Are you now, and have you been, in sound health for one year preceding this application? * Yes No If no, describe nature of impairment Do you intend to travel outside Canada or the U.S.A. during the next twelve months? Yes No If yes, state countries to be visited, length of stay, purpose Is your hearing impaired; have you ever suffered from any disease of the ears? Yes No If yes, to what extent? Is your sight in any way impaired; have you suffered from any disease of the eyes? Yes No If yes, to what extent? During the past five years have you undergone any surgical operation(s)? Yes No If yes, state month, date, year, reason; physician name & address Have you any reason to think that you may need to undergo a surgical operation in the future? Yes No If yes, state approximate date for surgery; reason for surgery Do you have insurance similar to that now being applied for? Yes No If yes, name of Insurer, policy benefits Have you made any claim(s) against an Insurer in respect of an accident? Yes No If yes, date of claim, nature of claim, amount of claim Have you ever been declined, or accepted on special terms, for Life Insurance or Accident and Health Insurance? Yes No If yes, state details Has any Life or Accident and Health Insurer ever cancelled, or declined to renew, your coverage? Yes No If yes, state month/year of action, reason for action Have you an application pending for any other Accident Insurance? Yes No If yes, state date of application, name of Insurer, benefit(s) applied for Have you ever had your driver’s license revoked for any period of time for driving while under the influence of drugs or alcohol? Yes No If yes, state details Do you sky-dive, or operate an aircraft, glider or balloon? Yes No If yes, please explain Do you scuba-dive or race automobiles, motorcycles or boats? Yes No If yes, explain Do you engage in other hazardous activities not shown above? Yes No If yes, state nature of activity, extent and frequency of participation If you use a motor vehicle in connection with your business or occupation, give your approximate annual mileage if this will exceed 18,000 miles/30,000 km (business and pleasure). DECLARATION I hereby warrant that the above statements are true and correct to the best of my knowledge and belief and, that I have not withheld any information which is calculated to influence the decision of the Insurer. I understand that non-disclosure or misrepresentation of a material fact will render this insurance null and void. NOTE: A material fact is one likely to influence acceptance or assessment of this application by the Insurer. If you are in doubt as to what constitutes a material fact you should consult your agent, or SUTTON SPECIAL RISK INC. I understand that signing this application does not bind me to complete the insurance but, I do agree that, should a Document of Insurance be concluded, this Application, and the statements made herein, shall form the basis of the insurance. Further, that SUTTON SPECIAL RISK INC. is hereby authorized as the sole representative for placement of this insurance. Please type name to sign Date MM DD YYYY Applicant/Owner (corporation/partnership/trustee or individual other than Proposed Insured) By (signature & title) Witnessed, by Licensed resident agent Thank you!
