AD&D Application

1. Personal Information

Policyholder: Doctors of BC Policy Number: 056/027444A

Name*

First NameMiddle NameLast Name

Doctors of BC Number*

Date of Birth*

Date

Email*

Confirmation Emailexample@example.com

Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry

2. Coverage Requested

Choose amount of member coverage in units of $100,000 up to a maximum of $2,000,000*

3. Beneficiary Designation

It is important that you designate a beneficiary for the Loss of Life benefit under the Accidental Death and Dismemberment insurance. Your designated beneficiary is the person who you choose to receive the life benefit amount if you die accidentally. Failure to designate a beneficiary will result in any life claim being paid to your Estate. (Payment for all losses under the "dismemberment" portion of this policy, such as loss of limb, etc. are payable to you.)

A revocable beneficiary is someone you choose that can be changed at any time without their permission. An irrevocable beneficiary cannot be changed without the written permission of the irrevocable beneficiary.

If you designate more than one beneficiary, you must indicate the percentage of the claim to be paid to each beneficiary (the total percentage for all beneficiaries combined cannot be more than 100%).

You may want to designate a "contingent beneficiary" - an alternate beneficiary who you want to have the death benefit paid to in the event the beneficiaries you designated as primary beneficiaries are not living at the time of your death.

If you designate a beneficiary who is a minor (under the age of 18), please name a trustee to receive payment on behalf of the minor.

Loss of Life Primary Beneficiary Designation (All other losses are payable to the member)*

Loss of Life Contingent Beneficiary Designation (All other losses are payable to the member)

Complete this section if a beneficiary named on this form is a minor. If so, you
agree that if the beneficiary is a minor on the date that benefits become payable,
the benefits will be paid to the trustee to hold in trust for the minor until the minor
comes of age.

Trustee for Minor Children

PRIVACY: NOTICE CONCERNING PERSONAL INFORMATION

The information collected on this enrollment form is required for the purposes of reviewing and, if approved, processing this enrollment form. It may also be used to administer the insurance policy, protect against fraud, investigate and determine any claims that may be made under the policy, or as otherwise may be required by law.

This information, and information in existing files, may be used by Sutton Special Risk Inc., its agents, affiliates, partners, reinsurers, and authorized administrators for these purposes, regardless of whether a policy is issued or coverage ceases to be in force. Your information will only be shared as necessary.

Some of these entities may be located outside of Canada, therefore your information may be processed in a foreign jurisdiction, unless we are otherwise prohibited, where it will be subject to the laws of that jurisdiction.

This information may also be used to provide you with information about products and services that may be of interest to you. We do not disclose personal information to other organizations for marketing purposes. If you do not want us to use your information for these optional purposes or if you would like to access your personal information on file, you may contact us at privacy@suttonspecialrisk.com or Privacy Office, Sutton Special Risk Inc., 33 Yonge Street, Suite 400, Toronto, Ontario M5E 1G4. A copy of Sutton Special Risk’s privacy policy is available on our website or by request.

4. Authorization and Signature

Date*

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

ACCIDENTAL DEATH & DISMEMBERMENT ENROLLMENT FORM