Medical/Insurance History

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Have you any physical defects or infirmities of any kind?

Yes No

If yes ,give details

Do you participate in any sports or pastimes which render you liable to Injury?

Yes No

If yes ,give details

Are you now, or have you previously been insured in respect of personal accident insurance?

Yes No

If yes ,give details

Have you ever claimed for benefits under any accident insurance?

Yes No

If yes ,give details

SCHEDULE OF BENEFITS

THE INSURANCE AFFORDED HEREUNDER IS ONLY WITH RESPECT TO SUCH AND SO MANY OF THE INDEMINITIES AS ARE INDICATED BY A SPECIFIC AMOUNT SET BELOW EACH SUCH INDEMNITY LISTED IN THIS SCHEDULE AND IS ONLY WITH RESPECT TO INSURED PERSONS IN THE CLASSES DESIGNATED HEREIN.

ACCIDENTAL DEATH & DISMEMBERMENT/PERMANENT TOTAL DISABLEMENT	$ 500,000
ACCIDENT MEDICAL EXPENSES REIMBURSEMENT	$ 50,000
TOTAL RISK PREMIUM	$ 4,200
STAMP DUTY	$ 200