IA Accident Insurance

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Email
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First Name
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Last Name
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Tag 1
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D & D Allow
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Main Form ID
Personal Information for (You)
Country of Birth*
Country
Place of Birth (State or Province)
What is your Citizenship?*
Full Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address
- Same as Above
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mobile Phone Number*
Identification
Type*
Province/Territory of Issue*
Number*
Expiry Date*
MM slash DD slash YYYY

Declaration of the Insured
I, the insured,
declare that I am not currently disabled and have no permanent physical or mental disability;*
- Yes
- No
understand that benefits for disability insurance in the event of an accident will be paid only for a total disability resulting from hospitalization, fracture, dismemberment, major laceration or major burn;*
- Yes
- No

Beneficiary Information for (You)
Primary Beneficiary(s)Your primary beneficiary(s) are first in line to receive the life insurance proceeds in the event of your death. If you have one beneficiary then they will receive 100% of the proceeds, and if you have several beneficiaries it will be split between them depending on the share percentage you choose.
Full Name*

Date of Birth*

Gender*

Relationship*

Please specify

Share %*

Would you like to be able to change the beneficiary without having his/her consent?*
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Benficiary Full Name
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Benficiary Date of Birth
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Benficiary Gender
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Benficiary Relationship
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Benficiary Specify
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Benfeficiary Share
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Benfeficiary Consent

Billing For (You)
The first monthly premium will be withdrawn 3 business days after the application has been approved. A monthly premium will be withdrawn on your chosen withdrawal date.

Providing your bank info today will not result in a payment being withdrawn. You may cancel your policy at any time without any penalty. If the policy is not approved for any reason no charges will be made to your bank account.
Banking Information
Name of Account Holder*
Branch no*
Institution no*
Account no*
Name of Financial Institution*
Address of Financial Institution
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Account Type*
Withdrawal Date*
Withdrawals Are*
How did you hear about us?
Other
*
- I agree to the Client Disclosure terms.
*
- I agree to the Client PAD Agreement terms.

Personal Information for (You)