Application Form For Personal Accident Coverage (Page 2 of 2) in pdf

APPLICATION FOR PERSONAL ACCIDENT COVERAGE

Yes

Section D

Approximate total of other insurance in force or pending on your life: $ _________________ .

Have you ever had an application for life, disability, health, critical illness or personal accident

GENERAL

coverage declined, accepted on special terms, cancelled or non-renewed? …………………………….

INFORMATION

Have you made any claim(s) against an Insurer in respect of an accident?……………………………...

Do you intend to travel outside Canada or the U.S.A. during the next 12 months? ……………………..

(Provide

Give details in Section F, including countries to be visited, expected length of stay and purpose.

details of any

Have you ever flown as a pilot, or do you anticipate doing so in the next 12 months? ………………….

“Yes” answers

a. Have you ever participated in motorized vehicle racing, scuba diving, sky diving, hang gliding,

in Section F

mountain, rock or ice climbing, heli-skiing, or any other hazardous sport or avocation? ……………

below)

b. Do you anticipate doing so in the next 12 months? ……………………………………………………..

Have you ever been convicted of driving while under the influence of drugs or alcohol, or

had your driver’s license suspended or revoked for any reason, or is any such action pending?…….

If yes, Driver’s license # _________________________________________ Province ___________

Yes

Section E

Height _____________

ft’.in”.

Weight ____________

kg.

lbs.

In the past 10 years have you had, been medically diagnosed as having, or been treated for:

HEALTH

a. dizziness, fainting, seizures, stroke or other disorder of the brain or nervous system? ……………..

QUESTIONS

b. depression, burnout, chronic fatigue or other psychological, emotional or behavioral disorder? ….

c. high blood pressure, a heart condition, or diabetes? ……………………………………………………

(Provide

d. backache, rheumatic fever, rheumatism, arthritis, fibromyaligia, paralysis or other disorder of the

details of

muscles or bones, including joints and spine?……………………………………………………………

“Yes” answers

e. any disorder of the eyes or ears?…………………………………………………………………………..

in Section F

In the past 10 years, have you sought or received advice or treatment for the use of alcohol or

below)

drugs, or used cocaine, barbiturates, or any other narcotics? ……………………………………………..

Have you ever been medically diagnosed as having, or been treated for AIDS or HIV infection? …….

Have you ever attempted to commit suicide? ………………………………………………………………..

Are you totally disabled, or on sick leave, medical leave, or hospitalized?………………………………..

In the past 5 years, have you missed more than 15 consecutive days from work due to an injury? …..

Are you contemplating medical attention or a surgical operation?…………………………………………

Please provide additional details of any “Yes” answers in Section D or Section E, and any other information you feel

Section F

is material to your insurance application:

ADDITIONAL

INFORMATION

Section G

I hereby warrant that all information recorded in this application is, to the best of my knowledge and belief, true and

complete. I understand that non-disclosure or misrepresentation of a material fact will render this insurance null and

void. (A material fact is one likely to influence Underwriters in relation to acceptance of this application or the terms

DECLARATION

of coverage offered.

If you are in doubt as to what constitutes a material fact you should consult Hunter

McCorquodale).

Signed at ______________________________ this __________ day of ________________________ , ______

Signature of Proposed Insured: ………………………………………………………………………………………………

Signature of Owner, if other than Proposed Insured: ……………………………………………………………………..

If owner is corporation print name and title of person signing: _______________________________________

Broker Declaration: I certify that I have no knowledge of information that is not fully disclosed.

Signature of Agent/Broker: ……………………………………………………………………………………………………

For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Lloyd’s Underwriters’ insurance business in Canada.

HM-PA (02/14)

Page 2 of 2

Application Form For Personal Accident Coverage Page 2

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