Sports App Med

8/4/2019 Sports App Med

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SPORTS APPLICATION FORM AND

MEDICAL EXAMINERS REPORT

PART 1 - APPLICATION FORM

The Applicant must answer all questions on pages 1 through 11. All questions must be answered in ink. Pleasemake sure pages 11 & 19 are properly signed and dated.

PART 2 - MEDICAL EXAMINERS REPORT

All questions on pages 12 through 19 must be answered by the Medical Examiner upon examination of theApplicant. All questions must be answered in ink. The Medical Examiner should make sure that page 19 is

properly signed and dated.


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Suite 42033 Yonge StreetToronto, On tarioM5E 1S9(416) 366-2223Fax: 366-4608Web site: www.wjsutton .com

Insurance effected through

PART 1 - APPLICATION FORM

SECTION 1.

TO BE

COMPLETED

BYAPPLICANT

ALL QUESTIONS MUST BE ANSWERED IN INK.

1. Name in full

2. Address

3. Birth Sex FDate

month day year weight height

4. Sport Professional Collegian Other

5. Name of team

6. Position

7. Do you have any other employment full or part-t ime? Yes No

If Yes , describe

QUESTIONS 8 - 14 ARE NOT APPLICABLE IF COLLEGIATE STATUS

8. Employer

9. Address

10. Nature of Employers Business

11. Date of expiry of current contract (if applicable)

12. Are you actively working in your occupation? Yes No

If No , please give reasons

13. How long have you been working as a professional in this occupation?

Other employment, last five years

14. POLICY OWNER - please check Insured Other

Name and address of Policy Owner (if other than Proposed Insured)

Relationship to Proposed Insured

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NOTE: IN THE EVENT THAT ANY QUESTION HAS NOT BEEN ANSWERED SATISFACTORILY,

UNDERWRITERS RESERVE THE RIGHT TO EITHER, RETURN THIS FORM TO THE APPLICANT

FOR THE ANSWERS TO BE COMPLETED, OR TO IMPOSE ANY RESTRICTION, OR PRE-EXISTINGCONDITIONS EXCLUSION ON THE COVERAGE REQUIRED UNTIL SUCH TIME AS THE

APPLICATION HAS BEEN SATISFACTORILY COMPLETED.

SECTION 2. 1. Are you currently free

Yes

No. Explain fully:of injury, illness or discomfort?

2. Are you currently physically able Yes No. Explain full y:to perform all of the duties requiredin your sport as stated in Section 1of the Application Form?

3. Have you missed any playing time No Yes. Explain fully:during the last 24 months as a resultof injury, illness, discomfort orfor any other reason?

5. Name and address of Personal Physician.

6. If you have consulted your Personal Physician in the last24 months, please give date and reason forconsultation.

7. Does the Physician named in the Yes Noquestion above also act as the physicianfor the team for which you play?

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Additional Comments:

8. Have you consulted your team No Yes. Physicians Name/ Address, reasons:physician or any other physicianin the last 24 months other than forroutine examination or team physical?

4. Do you require any type of knee brace No Yes. Explain fully:while playing or practising?


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SECTION 3.

1. Have you within the last 24 months, No f Yes, what are you taking and how often?taken any pain reducing oranti-inflammatory medication?

2. During the last twelve (12) months No f Yes, what were the symptoms and how longhave you suffered any injury, sickness did they persist?

or discomfort for which you have notsought medical advice?

3. Have you been advised or do you No Yes. Explain fully:have reason to believe that you mayneed medical treatment in the future?

4. Have you ever been advised to No Yes. Explain fully:have treatment which has not

been undertaken?

SECTION 4.1. Piloting an aircraft? No Yes. Explain fully:

2. Skydiving or hang-gliding? No Yes. Explain fully:

3. Water or underwater sports? No Yes. Explain fully:

4. Winter sports, other than skating or curling? No Yes. Explain fully:

5. Motor sports or motorcycling? No Yes. Explain fully:

6. Rock climbing or mountaineering? No Yes. Explain fully:

7. Any other activities excluded by No Yes. Explain fully:your club contract?

Do youengage in

any of the

followingactivities, or

any other

similaractivity,

which may be

consideredhazardous;

Provide full

details

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SECTION 5.1. Head? No Yes. Explain fully:

Have youever injured

or suffered

pain ordiscomfort,

or had

surgery to

any of thefollowing:

If yesplease give

details

includingdates.

2. Neck (Cervical Spine)? No Yes. Explain fully:

3. Right Shoulder (including Clavicle No Yes. Explain fully:and Shoulder Blade)?

4. Left Shoulder (including Clavicle

No

Yes. Explain fully:and Shoulder Blade)?

5. Chest (including ribs, sternum & No Yes. Explain fully:diaphragm)?

6. Upper Back? No Yes. Explain fully:

7. Lower Back (including tail bone)? No Yes. Explain fully:

8. Right H ip? No Yes. Explain fully:


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SECTION 5.

(Continued)

9. Left Hip? No Yes. Explain fully:

10. Right Groin? No Yes. Explain fully:Have youever injuredor suffered

pain or

discomfort,

or hadsurgery to

any of the

following:

If yes

please givedetails

including

dates.

11. Left Groin? No Yes. Explain fully:

12. Abdominal Muscles? No Yes. Explain fully:

13. Right Elbow? No Yes. Explain fully:

14. Left Elbow? No Yes. Explain fully:

15. Right Wrist? No Yes. Explain fully:

16. Left Wrist? No Yes. Explain fully:

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SECTION 5.

(Continued)

Have you

ever injuredor suffered

pain or

discomfort,

or hadsurgery to

any of the

following:

If yes

please givedetails

including

dates.

17. Right Hand (including fingers and thumb)? No Yes. Explain fully:

18. Left Hand (including fingers and thumb)? No Yes. Explain fully:

19. Right Thigh (including hamstring)? No Yes. Explain fully:

20. Left Thigh (including hamstring)? No Yes. Explain fully:

21. Right Knee? No Yes. Explain fully:

23. Right Lower Leg? No Yes. Explain fully:

22. Left Knee? No Yes. Explain fully:

24. Left Lower Leg? No Yes. Explain fully:

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1. Cardiac such as heart murmur, heart No Yes. Explain fully:attack, angina, chest pain, high orlow blood pressure, or any other diseaseof the heart or blood vessels?

2. Respiratory system such as asthma, No Yes. Explain fully:chronic bronchit is or emphysema,shortness of breath, pneumoniaor any other respiratory disease?

4. Nervous system such as No Yes. Explain fully:paralysis, anxiety, seizures,depression or any other mental disease?

3. Digestive such as ulcer, colitis, No Yes. Explain fully:bleeding, gallbladder or liverdisease or any other disorderof the stomach, intestines or rectum?

5. Endocrine such as diabetes, No Yes. Explain fully:thyroid, or any other glandulardisease?

SECTION 6.

Within thelast ten (10)

years, have

you evershown

indications of,

suffered from,

been treatedfor, or been

prescribed

treatment forany condition

of thefollowing:

7. Skin disease, cancer, cyst No Yes. Explain fully:or tumor?

8. Rheumatism, arthritis, No Yes. Explain fully:ruptured disc, or any disease,injury or deformity of thespine, joints, bones or muscles?

6. Any disease of the blood? No Yes. Explain fully:


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9. Any disease of the kidneys, No Yes. Explain fully:bladder, prostate or reproductiveorgans?

10. Any disease of the eyes, ears, No Yes. Explain fully:nose or throat?

11. Concussions, loss of No Yes. Explain fully (list all incidents including datesconsciousness, or and degree of severity)seizures?

12. Paralysis whether complete No Yes. Explain fully:or partial, regardless of length oftime or duration.

SECTION 6.(Continued)

Addit ional Comments:

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Within thelast ten (10)

years, have

you evershown

indications of,

suffered from,

been t reatedfor, or been

prescribed

treatment forany condition

of the

following:


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1. Are you now, or have you ever been No Yes. Explain fully:treated for substance or alcoholabuse?

2. Have you ever used marijuana, No Yes. Explain fully:mood-altering drugs, narcotics,cocaine, heroin, barbituates,LSD or amphetamines?

2. Has any insurance company ever No Yes. Explain fully:applied a specific exclusion to yourdisability policy?

SECTION 7.

1. Have you in the past applied for, No Yes. Explain fully:or purchased, any additional disabilitycoverage (i.e. accident and/or sickness)?

2. Have you ever tested positive for the No Yes. Explain fully:AIDS(HIV) virus?

SECTION 8.

SECTION 9.

1. Have you ever been diagnosed or No Yes. Explain fully:received treatment by a member of themedical profession for AIDS (AcquiredImmune Deficiency Syndrome) or ARC(AIDSrelated complex)?


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IT IS UNDERSTOOD AND AGREED AS FOLLOWS:

1. I have read the statements and answers recorded herein. They are to the best of my knowledge and belief, true and complete and

correctly recorded. The Insurer will rely on this information in making their determinations.

2. No agent, broker or medical examiner has authority to waive the answers to any question, to determine insurability, to waive any ofthe Insurers rights or requirements, or to make or alter any contract or policy.

3. The Insurer has the right to require medical exams and tests to determine insurability.

4. The insurance applied for will not take effect unless the health of the Proposed Insured remains as stated in the Application on theinception date of the proposed policy.

AUTHORIZATION

To all physicians, medical professionals, hospitals, cl inics, other health care providers, insurers, employers, Medical InformationBureau (MIB), consumer report ing agencies, other insurance support organizations, and other persons who have information aboutthe proposed insured.

I authorize you to give the Insurer, i ts reinsurers, i ts agents (a) all information you have as to il lness, injury, medical history, diagnosis,treatment, and prognosis with respect to any physical or mental condition of the proposed insured; and (b) any non-medicalinformation, including any investigative consumer report, which the company believes it needs to perform the business functionsdescribed below.

The information obtained will be used to determine if the Proposed Insured is eligible for (a) the insurance requested; or (b) benefitsunder a policy which is in force. It wi ll also be used for any other business purpose which relates to the insurance requested or the

policy which is in force.

The form will be valid for 36 months. I know that I may request a copy of it. I agree that a photocopy is as valid as the original.

month day year Signature of Proposed Insured

Name of Proposed Insured (PLEASEPRINT)

THE FOLLOWING DECLARATION IS ONLY TO BE COMPLETED WHERE A TEAM ISEFFECTING THIS INSURANCE ON BEHALF OF A PLAYER.

We hereby warrant that to the best of our understanding and belief, all the answers and statements herein contained are ful l,complete and true and have been correctly recorded and we do not know of any other information which is likely to influence thedecision of the Insurer and that we are willing to accept a Policy, subject to the terms and conditions of such Policy, to beissued on the basis of and in consideration of the proposal, which we understand shall be attached to and constitute a part of theContract of Insurance.

Signature of Team Official month day year Position Held

PLEASE READ CAREFULLY.


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PART 2 - MEDICAL EXAMINERS REPORT

ALL QUESTIONS MUST BE ANSWERED IN INK

ALL FOLLOWING SECTIONS TO BE COMPLETED BY MEDICAL EXAMINER ON EXAMINATION OF PLAYER

Name of Proposed Insured:

Current Vital Signs on this Examination

Height Weight

Blood Pressure Pulse

Please check the appropriate box

Normal Abnormal

Head,Eyes,Ears,Nose & Throat

Skin

Lungs

Heart

EKG

Abdomen

Genitalia

Respiratory

Circulatory

COMMENTS

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Have you examined and/or treated this patient in the past? YES, for years

NO


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HAS THE PROPOSED INSUREDSUFFERED DISCOMFORT,INJURY OR REQUIREDTREATMENT TO ANY OF THEFOLLOWING:

UPON EXAMINATION WERETHERE ANY ABNORMALITIESIDENTIFIED?

1. HEAD YES NO YES NO

DATES: DETAILS:(discomfort, injury, or abnormality)

Concussion details, if applicable.

DETAILS OF ANY SURGERYAND/ OR TREATMENT

CURRENT & FUTUREPROGNOSIS:

2. NECK (Cervical Spine) YES NO YES NO




3. RIGHT SHOULDER,CLAVICLE,SCAPULA YES NO YES NO




4. LEFT SHOULDER,CLAVICLE,SCAPULA YES NO YES NO




5. CHEST (Including Ribs, Sternum, Diaphragm) YES NO YES NO





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HAS THE PROPOSED INSUREDSUFFERED DISCOMFORT,INJURY OR REQUIRED

TREATMENT TO ANY OF THEFOLLOWING:


6. UPPER BACK (Thoracic Spine) YES NO YES NO




7. LOWER BACK YES NO(Lumbar spine incl. Coccyx and Sacral Spine)

YES NO




8. RIGHT HIP YES NO YES NO




9. LEFT HIP YES NO YES NO


DETAILS OF ANY SURGERYAND/OR TREATMENT


10. RIGHT GROIN YES NO YES NO





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11. LEFT GROIN YES NO YES NO




12. ABDOMINAL MUSCLES YES NO YES NO




13. RIGHT ELBOW YES NO YES NO




14. LEFT ELBOW YES NO YES NO




15. RIGHT WRIST YES NO YES NO





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16. LEFT WRIST YES NO YES NO




17. RIGHT HAND (Including fingers and thumb) YES NO YES NO




18. LEFT HAND (Including fingers and thumb) YES NO YES NO




19. RIGHT THIGH (Including hamstring) YES NO YES NO




20. LEFT THIGH (Including hamstring) YES NO YES NO





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21. RIGHT KNEE YES NO YES NO




22. LEFT KNEE YES NO YES NO




23. RIGHT LOWER LEG YES NO YES NO




24. LEFT LOWER LEG YES NO YES NO




25. RIGHT ANKLE (Including Achilles tendon) YES NO YES NO





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26. LEFT ANKLE (Including Achilles tendon) YES NO YES NO




27. RIGHT FOOT (Including toes) YES NO YES NO




28. LEFT FOOT (Including toes) YES NO YES NO






ADDITIONAL COMMENTS:

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On completion of physical examination, please provide your overall impression with regard to players ability to continue his career:

As a physician, please state your relationship to the proposed insured, i.e. Personal Physician, Team Physician, etc.

I certify that I made this examination on

month day year

EXAMINERS SIGNATURE APPLICANTS SIGNATURE

EXAMINERS NAME APPLICANTS FULL NAME

EXAMINERS ADDRESS

TELEPHONE NUMBER

FAX NUMBER

ANY ADDITIONAL COMMENTS

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