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Address:
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Profession or Occupation:
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(State
whether commercial duties only. Master Sups. Intending, Master
working with or without machinery or workman with or without machinery)
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Age next birthday:
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| Height:
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| Weight:
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| Have you ever proposed to insure Against accidents with this or any other office? If so, give particulars
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Has any proposal form you ever been
declined or has a policy in your favor ever been cancelled, or not renewed?
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| Are you now insured, or proposing to insure against accidents elsewhere? If so, give particulars
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| Have you ever met with an accident that confines you to the house for more than one week? If so, state particulars and period of disablement
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| Have you ever made a claim or received compensation for injuries or Disease? If so, state from whom and give date and particulars
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Are you now suffering or have you ever suffered from any disease or affection of the eyes?
Yes No
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Is your hearing impaired or have you ever suffered from inflammation of or any discharge from the ear or from any other car complaint?
Yes
No
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Are you ruptured or have you Varicose Veins, or any other physical defect or infirmity or are you suffering from any illness or disease of any kind?
Yes
No
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Have you ever suffered from Gout?
Yes
No
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Will the total amount of the
weekly compensation during disablement from this and all other
sources exceed the amount of your weekly salary or income?
Yes
No
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Do you ordinarily enjoy good health?
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Yes No
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Are you sober and temperate habits?
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Yes No
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Have you ever been vaccinated ? and, if so, when were you last vaccinated?
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Do you engage in racing of any kind motor cycling or aviation other than as a fare paying passenger on a recognized air line?
Yes No
Details
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Do you pursuits occupation or pastimes render you peculiarly liable to accidents?Yes No
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Have you any intention of traveling
abroad? If so, please state particulars
Yes
No
Details
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Sum to be insured in case by accident, with corresponding benefits
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Annual Premium:
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Class:
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Beneficiary:
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Declaration
I hereby declare that the above answers are true, without any reservation whatever and I agree that this Declaration be the basis of the policy to be granted to me by the Company which subject to the terms and conditions thereof, I agree to accept.
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Date:
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Proposal's Signature
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