Application Form For Personal Accident Coverage
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1
2APPLICATION FOR PERSONAL ACCIDENT COVERAGE
Underwritten by certain Underwriters at Lloyd’s, London, England through
Hunter McCorquodale
480 University Ave.
Suite 1100
Toronto, ON M5G 1V2
2. Birthdate:
3.Sex
1. Name of Proposed Insured:
Mr.
Mrs.
Ms.
Dr.
Other (specify)_____
Section A
____/____/____
Day Month Year
PERSONAL
4. Residence Address: (Street, Apt/Suite #, City/Town, Province, Postal Code)
5. Daytime telephone #:
INFORMATION
6. Mailing Address (if different from residence address):
7. Email address:
8. Owner, if other than Proposed Insured (owner must sign page 2):
9. Citizenship:
Canadian
Other (specify):_________________
1. Profession or Occupation:
Section B
2. Brief Description of Duties:
EMPLOYMENT
INFORMATION
3. Employer Name:
4. Employer Address:
5. Current Employment Status:
Employee
Unincorporated Business Owner/Partner
Incorporated Business Owner/Partner
6. Do you anticipate any material changes in your occupation or duties in the next 12 months?
Yes
No
If yes, give details:
7. Earned Income:
Earned Income Means:
Employee: Total salary, bonus and commission, less deductible employment
Estimated next 12 months $ _____________
expenses.
Unincorporated Business Owner/Partner: Your share of net business income
This year to date:
$ _____________
after normal and customary business expenses and before income tax.
Last year:
$ _____________
Incorporated Business Owner (>10%): Salary, bonus if consistent, and your
share of corporate net profit before income tax. All amounts should be on a
2 years prior:
$ _____________
fiscal year basis.
1. Principal Sum Insured: $
2. Currency:
CAD
USD
Section C
PLAN
4. Premium: $
3. Policy Term:
12 months
Other (specify):
INFORMATION
5. Beneficiary (if left blank, the beneficiary is the owner or the estate of the owner):
Name:
Relationship to Proposed Insured:
6. Coverage Type:
Accidental Death only
Accidental Death and Dismemberment
Accidental Death, Dismemberment and Permanent Total Disability
7. Scope:
All risk, 24 hour
Other (specify):
nd
nd
8. Optional Coverages:
War and Terrorism
Joint 2
to die (Submit completed application on 2
life)
9. Effective Date:
Date of approval
Other (specify):
10.a. What is the purpose of this coverage?
b. How was the amount determined?
HM-PA (02/14)
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