ACCIDENTAL DEATH & DISMEMBERMENT ENROLLMENT FORM

First Name*

Middle Name

Last Name*

Doctors of BC Number*

Date of Birth (DD/MM/YY)*

Date

Member Email*

Confirmation Emailexample@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you currently have existing AD&D coverage in effect with Doctors of BC?*

YesNo

Type of Coverage:*

Member OnlyFamily

Amount of Member Coverage (in units of $100,000 up to $2,000,000):*

Please enter the amount of coverage you wish to apply for ($100,000 - $2,000,000)

Do you have any adult child(ren) dependents who will be covered under this plan?*

YesNo

Change Type of Coverage to:*

Member OnlyFamilyNo Change in Coverage Type

Are you changing the coverage amount that is currently in force?*

YesNo

Change Amount of Member Coverage (in units of $100,000 up to $2,000,000) to:*

Please enter your desired total coverage amount ($100,000 - $2,000,000)

Do you have any adult child(ren) dependents who will be covered under this plan?*

YesNo

Do you want to change the existing beneficiary designation on your AD&D coverage?*

YesNo

INSTRUCTIONS FOR COMPLETING THE BENEFICIARY DESIGNATION FORM - AD&D

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

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%

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)*

	Name (first, middle, last)	Relationship to Member	Revocable/Irrevocable	% Share
Beneficiary #1
Beneficiary #2
Beneficiary #3

Revocable/Irrevocable status: Please indicate whether each beneficiary is revocable or irrevocable.

Revocable status is recommended as to allow simple policy and beneficiary changes by the plan owner.

When you name an irrevocable beneficiary, you cannot make any changes to the policy (i.e. cancel, reduce benefits or change beneficiary) without the written consent of the irrevocable beneficiary.

Are any beneficiaries listed above younger than 19?*

YesNo

In respect of minors, please name a trustee below to receive payment while the beneficiary is a minor*

Please do not name anyone already designated as a beneficiary in the table above.

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 in Section 2 are not living at the time of your death. If so, please complete this section. If you designate a contingent 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 CONTINGENT BENEFICIARY DESIGNATION (All other losses are payable to the Member)

	Name (first, middle, last)	Relationship to Member	Revocable/Irrevocable	% Share
Beneficiary #1
Beneficiary #2
Beneficiary #3

Revocable/Irrevocable status: Please indicate whether each beneficiary is revocable or irrevocable.

Revocable status is recommended as to allow simple policy and beneficiary changes by the plan owner.

When you name an irrevocable beneficiary, you cannot make any changes to the policy (i.e. cancel, reduce benefits or change beneficiary) without the written consent of the irrevocable beneficiary.

Are any beneficiaries listed above younger than 19?*

YesNo

In respect of minors, please name a trustee below to receive payment while the beneficiary is a minor*

Please do not name anyone already designated as a beneficiary in the above tables.

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 270, Toronto, Ontario M5E 1G4. A copy of Sutton Special Risk’s privacy policy is available on our website or by request.

Signature of Member - approving beneficiary designation.*

Signature of Member*

Date (DD/MM/YY)*

Date

ACCIDENTAL DEATH & DISMEMBERMENT ENROLLMENT FORM

SECTION 1 - PERSONAL INFORMATION

SECTION 2 - COVERAGE REQUESTED - NEW APPLICATION

SECTION 3 - COVERAGE REQUESTED - CHANGE IN COVERAGE

ACCIDENTAL DEATH AND DISMEMBERMENT BENEFICIARY DESIGNATION

Section 1 - Loss of Life Primary Beneficiary Designation

Section 2 - Contingent Beneficiary Designation

SECTION 3 - AUTHORIZATION AND SIGNATURE