Motor racing questionnaire - Manulife › content › dam › manulife... · What type(s) of flying...

Motor racing questionnaire

Manulife, Individual Insurance 500 KING STREET NORTH, PO BOX 1669, WATERLOO ON N2J 4Z6

1 Information about person to be insured

Application/Policy number Name (first, middle initial, last) Date of birth (dd/mmm/yyyy)

2 Details 1. Tell us: Auto Cycle Snowmobile Boat Other:

__________

Number of years racing

Number of races in the last 12 months

Number of races planned in the next 12 months

Maximum speed (km/h)

Average speed (km/h)

Maximum distance (km)

Average distance (km)

Make/model/engine size & horsepower

Type of track

open

closed

oval

straightaway

open

closed

oval

straightaway

open

closed

oval

straightaway

oval

straightaway

Type of surface

paved

dirt

other

paved

dirt

other

ice

snow

other

Affiliation with any racing organizations or clubs yes

no

yes

no

yes

no

yes

no

yes

no

2. Do you race professionally? No Yes

• If yes, what percentage of your annual income is earned from racing? %

3. Have you done or do you plan to do any stunt driving? No Yes

4. What type(s) of vehicles do you currently use or plan to use?

Sports cars Formula Go-carts

ABC Formula 1 Hot rod

All American GT 2000 Midget

Camel 3000 Mini

Can Am Atlantic Sprint

IROC Ford Vintage

Porsche Indy Other (provide details)

Production If yes, confirm production type

A, B, C, D, E, F, G or H

V ________________________ Super V

________________________ __________

Trans Am

5. What class of racing or competition do you participate in or plan to participate in?

All terrain Drag Off-road

3 wheel Dragsters Off-shore powerboat

4 wheel Top fuel Timespeed trials

Autocrash Gasoline Track

Closed circuit Dune/sand buggies Other (provide details)

Cross country Enduro ________________________ Demolition derby Hill climbing

The Manufacturers Life Insurance Company Page 1 of 2 NN9434E MOTOR (12/2013)

2 Details (continued) 6. List the names of bodies that govern the races in which you compete:

7. Are you a member of a racing association or affiliated club? No Yes

• If yes, tell us the name and website address of your local club and its national affiliate

Local club website, if available

National club website, if available

8. Have you ever had an accident participating in any of these activities? No Yes

• If yes, provide details:

3 Authorization By signing below, you certify that all the information in this form is complete, current and accurate and

that this information forms part of your application for insurance.

Date (dd/mmm/yyyy) Signature of witness

✘ Signature of person to be insured

✘

The Manufacturers Life Insurance Company Page 2 of 2 NN9434E MOTOR (12/2013)

Aviation questionnaire



Application/Policy number Name (first, middle initial, last)

1. What type(s) of licence or permit do you hold? recreational permit student pilot licence

private pilot licence other ________________

2 Details

To be completed by pilot. 2. Do you have your instrument flight rating (IFR)? No Yes

3. What type(s) of aircraft do you pilot? Select all that apply.

If you fly more than one type, tell us the percentage of time spent in each.

fixed wing ______ % helicopter ______ % military ______ %

other ________________________ ______ %

4. Have you flown or do you expect to fly any other type of aircraft? No Yes • If yes, explain:

5. How was the aircraft built? factory built home built

6. Do you fly from a private airstrip? No Yes

7. Do you fly over large bodies of water or mountainous areas? No Yes

8. Have you ever had an aviation accident, been grounded, fined or warned for violation of air regulations?

No Yes • If yes, provide details including dates:

9. Type of flying (specify aircraft if varied) Anticipated hours (next 12 months)

Hours flown between 13 and 24 months ago

aerobatics/air racing

advertising

air ambulance

Date of birth (dd/mmm/yyyy)

bush pilot/game fisheries

Date issued (dd/mmm/yyyy) Total number of hours flown as a pilot

Date of birth (dd/mmm/yyyy)

commercial photography

crop dusting

employer owned planes

forestry services

heavy lifting by helicopter

instruction

mapping/surveying

nonscheduled air carriers

pipeline inspection

recreational

water bombing

military (specify type of craft)

test/experimental (specify type of craft)

Other (explain)

10.Do you have any operational limitations on your FAA/DOT medical certificate? No Yes • If yes, explain:

11. Have you participated in, or do you plan to participate in, any type of flying not already mentioned above?

No Yes • If yes, provide details:

By signing below, you certify that all the information in this form is complete, current and accurate and

that this information forms part of your application for insurance. 3 Authorization

Date (dd/mmm/yyyy) Signature of witness Signature of person to be insured

✘ ✘

The Manufacturers Life Insurance Company NN9434E AVIATN (12/2013)

Hours flown in past 12 months

Ballooning or Ultralight flying questionnaire



2 Details


1. Do you fly a balloon or an ultralight professionally? No Yes

• If yes, what percentage of your annual income is earned from this activity?

2. Do you have a valid licence for the type of craft you fly? No Yes

3. What type(s) of crafts do you currently use or plan to use? Select all that apply

Balloon

hot air

helium

hydrogen

other: ________________

Ultralight

motorized

non-motorized

4. How was the craft built? Select all that apply.

factory assembled home assembled home built

5. Who owns the craft?

person to be insured club other: _________________

6. What type(s) of flying you have done or do you plan to do? Select all that apply.

tethered free flight record attempts ocean crossing

using experimental craft or prototypes other: _________________

7. How many years have you been flying?

a balloon _____ years an ultralight _____ years


9. Are you a member of a ballooning and/or an ultralight association or affiliated club? No Yes

• If yes, tell us the name and website address of your local club and its national affiliate:


10.Are you an instructor? No Yes

11. Do you have experience flying other aircraft? No Yes • If yes, provide details:

12.Describe your flying history. If you fly more than one type of craft, complete a questionnaire for each type.

Instructing or business

Other (Specify) _____________

Pleasure

Total number of flights to date

Number of flights in the last 12 months

Number of flights planned in the next

12 months

Average height

Longest distance

Competitive

13.Have you been involved in any reportable incident? No Yes • If yes, provide details:

3 Authorization



✘




%

Method of launch

The Manufacturers Life Insurance Company NN9434E BALLOON (12/2013)

Hang gliding/Paragliding questionnaire




2 Details 1. What type of craft do you currently use, or do you plan to use? Select all that apply.

Hang glider Paraglider

rigid wing motorized

flex wing non-motorized

motorized

non-motorized

2. How was the craft built? Select all that apply.

factory assembled home assembled home built

3. Do you carry a parachute? No Yes

4. What pilot rating level do you hold?

student novice intermediate advanced

5. What method(s) of launching do you use?

foot winch tow other: ____________________

6. Are you a member of a hang gliding and/or paragliding association or an affiliated club? No Yes





8. Have you ever or do you plan to participate in any form of competitive flying, record attempt or use of experimental

equipment? No Yes • If yes, provide details:

9. Have you ever or do you plan to fly from sites not officially approved by a club? No Yes • If yes, provide details:

10.Have you been involved in any reportable incident? No Yes • If yes, provide details:

11. Tell us: Hang gliding Paragliding

Number of years gliding yrs yrs

If you are an instructor, number of years instructing yrs yrs

Total number of flights to date flights flights

Total number of flights in the past 12 months flights flights

Number of flights planned in the next 12 months flights flights

Number of hours planned in the next 12 months hours hours




✘ ✘ Signature of person to be insured

The Manufacturers Life Insurance Company NN9434E GLIDING (12/2013)

Climbing questionnaire




2 Details 1. What type(s) of climbing do you currently do or plan to do? Select all that apply.

mountain indoor wall rock bouldering scrambling buildering

free solo trail snow ice glacier other: ______________

2. Tell us:

Type of climbing

Easy/ Moderate or Severe

Time of year

Height and duration of average

climb

Highest climb and

date of that climb

*For Location, provide details, e.g. National Park, province, name of mountain; Specify country and/or mountain if you climb outside of Canada. If you need more space, copy and complete another questionnaire.

3. What is the maximum technical grade of your climbs and the applicable grading system (e.g. Yosemite Decimal System (YDS) grade 5.4)? :

4. Have you taken courses for the type of climbing you do? No Yes

• If yes, tell us which courses and when:

5. Tell us the equipment you typically carry for each type of climbing you do:

rope rope ladder piton ice axe none

crampon oxygen belay other: _________________

6. Are you a member of a climbing association or an affiliated club? No Yes




7. Do you ever climb alone? No Yes

• If yes, tell us how often, the climb location(s) and the degree of difficulty:

8. Within the next two years, do you plan to participate in other types of climbing or in more difficult climbs?

No Yes • If yes, tell us the details:

9. Have you been involved in a climbing accident in which you injured yourself? No Yes



that this information forms part of your application for insurance. 3 Authorization


✘ ✘

Number of years

climbing Location(s)*

Number of climbs each

year

The Manufacturers Life Insurance Company NN9434E CLIMB (12/2013)

Parachuting/Skydiving questionnaire



2 Details

8. Have you ever or do you plan to participate in jumps requiring floatation gear because of proximity to water?

No Yes • If yes, tell us how often, the date of your last water jump and/or the date of the planned water jumps.



1. What licence or certification do you have?

2. What parachuting or skydiving courses have you taken?

3. What type(s) of parachuting or skydiving do you currently do or plan to do? Select all that apply.

free fall tandem solo static line canopy swooping

professional instructing sky surfing extreme (Specify): ___________

other (Specify): ______________________

4. Have you ever done or do you plan to do BASE (Building, Antenna, Span, Earth) jumps? No Yes

5. Are you a member of a parachuting or sky diving association or an affiliated club? No Yes


6. Are all your jumps at a club drop zone or at a site approved by your club? No Yes

• If no, provide details:

7. Have you ever or do you plan to jump at night? No Yes

• If yes, tell us how often, the date of your last night jump and/or the date of any planned night jumps.

9. Have you ever or do you plan to compete for jump records or use experimental equipment? No Yes


10.Have you ever jumped or do you plan to jump wearing special gear (e.g. a wingsuit designed to maximize free-fall

gliding)? No Yes • If yes, provide details:

11. Have you ever had an accident or have any of your actions caused a documented safety infraction?

No Yes • If yes, provide details:

12.Describe your jump history and plans:

Number of jumps to date in the next 12 monthsin the past 12 months



✘




3 Authorization

The Manufacturers Life Insurance Company NN9434E SKYDIVE (12/2013)

Scuba or skin diving questionnaire


1. Do you dive professionally? No Yes

• If yes, what percentage of your annual income is earned from diving?

2. Are you certified by a recognized licensing authority (e.g. PADI, NAUI, YMCA)? No Yes

• If yes, tell us the recognized licensing authority. ___________________________

3. What is your level of certification?

basic open water advanced open master diver

dive master instructor assistant instructor other: _______________

4. When were you last certified?

5. What type(s) of diving do you do? Select all that apply.

rescue medic first aid search & recovery recreational open water

ice night deep wreck

cave high altitude drift commercial (Specify:__________________)

other: ___________________

6. Have you completed the required training for each type of diving you do? No Yes

7. Where are your usual diving sites?

ocean lake river gravel quarry pool other: ______________

8. Do you participate in decompression dives? No Yes

• If yes, specify maximum depth: maximum bottom time:

9a.What is the date of your last dive? b. What is the date of your last decompression dive?


2 Details


Dive depth (in feet) Past 12 months

Number of dives Average time

Next 12 months

Number of dives Average time

less than 50

50-75

76-100

101-120

10.How many dives have you done to date?

11. Have you used or do you plan to use mixed gas (e.g. nitrox, trimix, heliox)? No Yes

• If yes, provide details including when and on what type of dive.

12.Do you ever dive alone? No Yes • If yes, tell us how often and the dive location(s):

13.Are you a member of a diving association or an affiliated club? No Yes

• If yes, tell us the name and website address of your local diving club and its national affiliate:



14.Tell us:

3 Authorization



✘



greater than 120

%

Date (dd/mmm/yyyy)

Date (dd/mmm/yyyy) Date (dd/mmm/yyyy)

The Manufacturers Life Insurance Company NN9434E SCUBA (12/2013)

Backcountry snow sports questionnaire

* To be completed if the backcountry snow sport is done in Alberta, BC or outside Canada




2 Details 1. What type(s) of snow sports do you participate in? Select all that apply.

Skiing: cross-country, downhill or touring Heliskiing Cat skiing

Snowmobiling (if racing, please also complete Motor racing questionnaire) Snowshoeing

Snowboarding Other (specify) ____________________________

2. For each type of snow sport you selected above tell us the following information:

Type of snow sport

Level of expertise __________________ Beginner Intermediate Expert Extreme

Where you participate Location

(Name of the mountain, province and nearest town. If outside of Canada, tell us the country)

Number of days in the past 12 months

Number of days planned in the

next 12 months

Established/marked or groomed trails

Backcountry

Posted out of bounds/closed

Other (specify)

Type of snow sport

Level of expertise __________________ Beginner Intermediate Expert Extreme





next 12 months


Backcountry


Other (specify)

Type of snow sport

Level of expertise__________________ Beginner Intermediate Expert Extreme





next 12 months


Backcountry


Other (specify)

Type of snow sport ___

Level of expertise _______________ Beginner Intermediate Expert Extreme





next 12 months


Backcountry


Other (specify)

The Manufacturers Life Insurance Company Page 1 of 2 NN9434E BKCNTRY (12/2013)

3. What type of terrain is commonly found where you participate in these activities?

Flat, easy low angled terrain such as beginner runs at ski resort

Steeper, more challenging terrain 30-35 degrees (expert level at resort)

Over 35 degrees

Over 55 degrees

2 Details (continued)

4. Do the areas where you participate in these activities post warnings for any of the following risks?

Select all that apply.

Avalanche

Rockfall

Crevasses

Other (specify)

5. If you participate in snowmobiling, have you or members of your party ever attempted high marking or do you plan

to do so? No Yes

• If yes, tell us the date of the last attempt.

6a.Do you carry safety gear/equipment when you participate in these activities? (Example: radio, GPS-global

positioning system, avalanche transceiver, flares, probes, shovels, etc.) No Yes

• If yes, tell us what equipment.

6b. If you participate in these activities with other people, do those people carry safety gear/equipment?

No Yes

• If yes, tell us what equipment.

7. Do you ever participate in any of these activities alone? No Yes

• If yes, tell us which activities.

10.Do you plan to participate in a different snow sport than you currently do? No Yes

• If yes, tell us what type(s).




3 Authorization

✘ ✘

8. Do you participate in the activities through the services of a licensed operator? No Yes

• If yes, tell us the name of the ski resort and/or tour operator.

9. Do you plan to change your pattern of participation in any of these activities? No Yes

• If yes, tell us how your pattern will change (Example: more/less per year; more/less challenging terrain)

The Manufacturers Life Insurance Company Page 2 of 2 NN9434E BKCNTRY (12/2013)

Yes

Yes

Yes

Asthma questionnaire



2 Details


1. When did the asthma first start? ____

2. When was your last attack?

3. How often do you have an asthma attack?

daily weekly monthly

yearly less than yearly seasonal other

4. How many attacks did you have in the last year?

5. Do you suffer from wheezing or shortness of breath between attacks? No Yes

6. Have you been hospitalized or needed to go to an emergency room or clinic within the last two years? No • If yes, tell us the following information:

3 Authorization



✘



Name of hospital or clinic

Test Results

pulmonary/lung function

Date(s) of test (mmm/yyyy)

Address

Date(s) on which you were hospitalized or received emergency treatment (dd/mmm/yyyy)

7. Have you had any of the following tests? Select all that apply and tell us test dates and results.

8. Have you been referred to a specialist? No • If yes, tell us the following information:

Name of specialist Address

Date you were referred to the specialist (mmm/yyyy)

used in the past year?

inhaler-corticosteroid

using now?

9. Describe your medications. (If none, select that option.):

inhaler-bronchodilator

inhaler-type unknown

oral steroids (e.g. Prednisone)

other (specify): _____________

none

10.Do you have any physical restrictions? No

• If yes, describe:

______________Date (mmm/yyyy)

Date (mmm/yyyy)

chest X-ray

other: ____________________

Date you saw the specialist (mmm/yyyy)

The Manufacturers Life Insurance Company NN9434E ASTHMA (12/2013)

Yes

Yes

Yes

Diabetes (including gestational diabetes) questionnaire


11. If you had gestational diabetes, did it resolve after your delivery? No

6. When was your last blood sugar level reading and what was it?

7. How often do you see your doctor?

more than once a year annually less than once a year

other


2 Details


1. How long have you had diabetes?

2. What type of diabetes do or did you have?

Type 1 Type 2 gestational diabetes

elevated blood sugar levels/ impaired glucose tolerance

3. What type of treatment are you currently using? Select all that apply.

diet insulin insulin pump oral medication

other (specify)

3 Authorization



✘



8. Have you been referred to a specialist? No • If yes, tell us:

Name of doctor Address

Date of last consultation (dd/mmm/yyyy)

Years


Date you were referred to the specialist (dd/mmm/yyyy)

9. Have you been hospitalized within the last two years? No • If yes, tell us the following information:

Name of hospital Address

10.Have you had gestational diabetes? No Yes

• If yes, tell us how many times you had this condition and the date of the last occurrence.

Number of times

Dates (dd/mmm/yyyy)

4. Have you experienced any of the following complications? Select all that apply.

insulin reactions diabetic coma neuropathy

retinopathy or other eye trouble repeated infections

ECG abnormalities circulatory trouble

protein in urine other

Date (dd/mmm/yyyy)

5. How frequently do you test your blood sugar levels?

Reading (numeric values)

Date you saw the specialist (mmm/yyyy)

Date of last occurrence (dd/mmm/yyy)

The Manufacturers Life Insurance Company NN9434E DIABETE (12/2013)

Gastrointestinal questionnaire




2 Details 1. Have you ever had, been told you had, been investigated for or treated for any of the following conditions?

Select all that apply.

Colitis

ulcerative proctitis spastic other: _____________________

Crohn’s disease

Diverticulitis

Irritable bowel syndrome

other: _____________________

2. When were you diagnosed with the condition?

Condition Date you were diagnosed (mmm/yyyy)

3. How many flare-ups, attacks or recurrences have you had in the past five years?

4. When was the last episode?

Date (dd/mmm/yyyy)

5. What is the frequency of episodes per year?

Frequency (e.g. three per year for the past five years)

6. Have you experienced any of the following complications in the past 12 months? Select all that apply.

malabsorption infection hemorrhage perforation

fistula obstruction weight loss other ________________________

• If weight loss, tell us the amount lost ________________________

For any that you selected, tell us what treatment or medication was prescribed?

Complication Treatment or medication

7. Have you had, or has it been recommended that you have, any of the following tests or procedures?

• If yes, tell us the test or procedure, the date(s) and the results. Select all that apply.

Test Date(s) of test or procedure

(dd/mmm/yyyy) Results

Date(s) the test or procedure was

recommended if not yet completed (dd/mmm/yyyy)

colonoscopy

sigmoidoscopy

ultrasound

surgery

endoscopy

gastrointestinal series

biopsy

barium enema

The Manufacturers Life Insurance Company Page 1 of 2 NN9434E GASTRO (12/2013)

111.1. Have you been hospitHave you been hospitalized within the palized within the past five years?ast five years?

• If If yesyes, tell us the following information:, tell us the following information:

2 Details (continued) 8. List all medications you have taken in the past five years for any of the conditions identified above, and the dates

you took those medications.

Name of medication Date you started taking medication Date you stopped taking medication

9. How often do you see your doctor?

more than once a year annually less than once a year

other: ___________________________

Date of last consultation (mmm/yyyy)

Name of doctor Address

10.Have you ever been referred to a specialist? No Yes

• If yes, tell us:

Date you were referred to the specialist (mmm/yyyy) Date you saw the specialist (mmm/yyyy)


No Yes

•

Dates (dd/mmm/yyyy)

Name of hospital Address

12.Do you have any physical restrictions? No Yes






✘

The Manufacturers Life Insurance Company Page 2 of 2 NN9434E GASTRO (12/2013)

Alcohol usage questionnaire

Manulife, Individual Insurance, New Business & Underwriting 500 KING STREET NORTH, PO BOX 1669, WATERLOO ON N2J 4Z6

1. Describe your current alcohol consumption.


2 Details

Application/Policy number Name of person to be insured (first, middle initial, last) Date of birth (dd/mmm/yyyy)

3 Authorization

Date (dd/mmm/yyyy)Signature of person to be insured

✘

By signing below, you declare that to the best of your knowledge the information you have provided in

this form is current, correct and complete. You agree that this form is part of your application for

insurance.

2. Have you reduced your alcohol consumption in the past five years? No Yes

• If yes, explain why you reduced your alcohol consumption and record the quantity that you used to drink in each category below.

3. Have you ever been treated or counseled for alcohol usage, or has someone ever recommended that you seek treatment or counseling or reduce your alcohol consumption? (Counseling may have been provided by Alcoholics Anonymous, another support group or an individual.)

No Yes

• If yes, tell us details:

4. Have you ever been charged with any alcohol-related driving offences, lost your job, lost time from work or been arrested due to the influence of alcohol?

No Yes

• If yes, tell us dates and details:

5. Has any member of your immediate family been treated for or died due to excessive alcohol?

No Yes

• If yes, tell us dates and details:

Signature of witness

✘ Name of witness Date (dd/mmm/yyyy)

Date of treatmentDate treatment recommended (dd/mmm/yyyy)

Name of doctor, hospital, treatment centre, support group or individual from (dd/mmm/yyyy) to (dd/mmm/yyyy)

None

• If none, describe any past drinking behaviour, including the reason and the date you stopped drinking.

Frequency of useUsual quantity

bottles

Alcohol

Beer

from (mmm/yyyy) to (mmm/yyyy)daily weekly monthly yearly

Dates

glassesWine

ouncesLiquor

Frequency of useUsual quantityAlcohol

from (mmm/yyyy) to (mmm/yyyy)daily weekly monthly yearly

Dates

bottlesBeer

glassesWine

ouncesLiquor

The Manufacturers Life Insurance Company NN9434E ALCOHOL (12/2013)

Drug usage questionnaire

Manulife, Individual Insurance, New Business & Underwriting 500 KING STREET NORTH, PO BOX 1669, WATERLOO ON N2J 4Z6


Application/Policy number Name of person to be insured (first, middle initial, last) Date of birth (dd/mmm/yyyy)

2 Details 1. Are you using or have you in the past used any of the following?

(Select all that apply.)

Amphetamines such as Ecstasy Benzedrine

Speed Crystal meth

Other: _______________________

Barbiturates such as Amytal Seconal

Other: _______________________

Benzodiazapines such as Xanax Ativan

Other: _______________________

Opiates such as Heroin Morphine

Smack Opium

Other: _______________________

Narcotic analgesics such as Percocet Oxycontin

Other: _______________________

Solvents such as Aerosols Glue

Other: _______________________

Hallucinogens such as LSD DMT

Acid Peyote

Other: _______________________

Others such as Anabolic steroids Hashish

Other: _______________________


No Yes

Dexedrine Methadrine

Pure Pillz

Nembutal Luminol

Librium Valium

Demerol Methadone

Doda

Oxycodone Dilaudid

Gasses Nitrates

Mescaline Magic mushrooms

Marijuana Cocaine

Name of drug Usual quantity Frequency of use Dates

daily weekly monthly yearly from (mmm/yyyy) to (mmm/yyyy)

The Manufacturers Life Insurance Company Page 1 of 2 NN9434E DRUG (12/2013)

3 Authorization

Date (dd/mmm/yyyy)Signature of person to be insured

✘

By signing below, you declare that to the best of your knowledge the information you have provided in

this form is current, correct, and complete. You agree that this form is part of your application for

insurance.

Signature of witness

✘ Name of witness Date (dd/mmm/yyyy)

2. Have you ever been treated or counseled for drug abuse, or has someone ever recommended that you seek treatment or counseling or reduce your drug consumption? (Counseling may have been provided by Narcotics Anonymous, another support group or an individual.)

No Yes


Date of treatmentDate treatment recommended (dd/mmm/yyyy)

Name of doctor, hospital, treatment centre, support group or individual from (dd/mmm/yyyy) to (dd/mmm/yyyy)

2 Details (continued)

3. Have you ever suffered from any mental or physical impairment (such as a liver disorder, hepatitis, convulsions, blackouts, flashbacks, anxiety or memory loss) associated with drug use?

No Yes


4. Have you ever needed or sought medical attention or lost any time from work due to the use of any drug?

No Yes

• If yes, provide details, including dates and, if applicable, the name of the hospital you went to:

Date(s)Details Name and address of hospital (if applicable)

5. Have you ever been arrested, charged or convicted for any activity involving drugs? No Yes • If yes, provide details including dates:

6. Have you ever used a prescription drug other than as prescribed by your doctor? No Yes • If yes, tell us details:

The Manufacturers Life Insurance Company Page 2 of 2 NN9434E DRUG (12/2013)

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