Application Form - Disability Coverage printable pdf download

Application Form - Disability Coverage

APPLICATION FOR DISABILITY INSURANCE COVERAGE

Underwritten by certain Underwriters at Lloyd’s, London, England

through Hunter McCorquodale

480 University Ave., Suite 1100

Toronto, ON

M5G 1V2

1. Name of Proposed Insured:

Mr.

Mrs.

Miss

Dr.

Title___________

Section A

PERSONAL

First:

Middle:

Last:

Maiden if Applicable:

INFORMATION

2. Residence Address:

3. Date of Birth:

4. Age 5. Sex

_______ /_______ /_______

Street, Apt/Ste. #

City/Town

Prov.

Postal Code

Day

Month

Year

6. Mailing Address (if different from residence address):

7. Place of Birth (Province/Country):

Street, Apt/Ste. #

City/Town

Prov.

Postal Code

9. Social Insurance Number:

8. Telephone: Home (

)

Best time to Call: Best Place to Call:

11. Citizenship:

10. Owner, if other than Proposed Insured (owner must sign on page 4):

1. Employer (provide details for past 2 years):

Section B

a. Current Employer/Business Name:

e. Previous Employer/Business Name:

EMPLOYMENT

INFORMATION

b. Dates Employed

f. Dates Employed:

From:

To:

From:

To:

c. Address:

g. Address:

________________________________________________

_____________________________________________

d. Nature of Employers Business:

h. Nature of Employers Business:

Employee: How paid? ............

i. Current Employment:

Salary

Commission

Combination

Status

Unincorporated Business Owner/Partner

Incorporated Business Owner (>10% ownership): Date Incorporated____________

j. If self-employed:

Length of time self-employed_____________

Percentage Ownership Share:_________

No. of full-time employees (excluding owners):_________________

Fiscal Year-End

2. Duties:

a. Job Title:

b. Professional Designation/Degree:

c. Breakdown of Duties (total = 100%):

d. Description of Duties

Administrative/Office:

_____% _______________________________________________

Manual/Physical:

_____% _______________________________________________

Sales:

_____% _______________________________________________

Driving:

_____% _______________________________________________

Travel (outside North America):

_____% _______________________________________________

Supervision (outside office e.g. plant, jobsite):

_____%

_______________________________________________

3.a. How many months a year

b. How many hours a week

c. How many hours a week do

do you usually work?

you usually work at home?

d. Length of time employed

e. Length of time employed

f. Are you actively working

Yes

in current job:

in similar job:

at your full-time job?

g. Do you have a part-time

Yes

If “yes”, describe exact duties:

or seasonal job?

h. Do you plan to change your duties,

Yes

If “yes”, give details:

occupation, or country of residence?

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Application Form - Disability Coverage

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