APPLICATION FOR PERSONAL ACCIDENT COVERAGE
Underwritten by certain Underwriters at Lloyd’s, London, England through
480 University Ave.
Toronto, ON M5G 1V2
1. Name of Proposed Insured:
Day Month Year
4. Residence Address: (Street, Apt/Suite #, City/Town, Province, Postal Code)
5. Daytime telephone #:
6. Mailing Address (if different from residence address):
7. Email address:
8. Owner, if other than Proposed Insured (owner must sign page 2):
1. Profession or Occupation:
2. Brief Description of Duties:
3. Employer Name:
4. Employer Address:
5. Current Employment Status:
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?
If yes, give details:
7. Earned Income:
Earned Income Means:
Employee: Total salary, bonus and commission, less deductible employment
Estimated next 12 months $ _____________
Unincorporated Business Owner/Partner: Your share of net business income
This year to date:
after normal and customary business expenses and before income tax.
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: $
4. Premium: $
3. Policy Term:
5. Beneficiary (if left blank, the beneficiary is the owner or the estate of the owner):
Relationship to Proposed Insured:
6. Coverage Type:
Accidental Death only
Accidental Death and Dismemberment
Accidental Death, Dismemberment and Permanent Total Disability
All risk, 24 hour
8. Optional Coverages:
War and Terrorism
to die (Submit completed application on 2
9. Effective Date:
Date of approval
10.a. What is the purpose of this coverage?
b. How was the amount determined?
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