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. Please make 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 the Applicant. All questions must be answered in ink. The Medical Examiner should make sure that page 19 is properly signed and dated.
Insurance effected through
Suite 420 33 Yonge Street Toronto, Ontario M5E 1S9 (416) 366-2223 Fax: 366-4608 Website: [Link]
PART 1 - APPLICATION FORM
ALL QUESTIONS MUST BE ANSWERED IN INK. SECTION 1. 1. 2. Name in full Address
TO BE COMPLETED BY APPLICANT
3.
Birth Date
month day year weight height
Sex
4. 5. 6. 7.
Sport Name of team Position Do you have any other employment full or part-time? If Yes, describe Yes No
Professional Collegian
Other
QUESTIONS 8 - 14 ARE NOT APPLICABLE IF COLLEGIATE STATUS
8. 9.
Employer Address
10. 11. 12.
Nature of Employers Business Date of expiry of current contract (if applicable) Are you actively working in your occupation? If No, please give reasons Yes No
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
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-EXISTING CONDITIONS EXCLUSION ON THE COVERAGE REQUIRED UNTIL SUCH TIME AS THE APPLICATION HAS BEEN SATISFACTORILY COMPLETED.
SECTION 2.
1.
Are you currently free of injury, illness or discomfort?
Yes
No. Explain fully:
2.
Are you currently physically able to perform all of the duties required in your sport as stated in Section 1 of the Application Form? Have you missed any playing time during the last 24 months as a result of injury, illness, discomfort or for any other reason?
Yes
No. Explain fully:
3.
No
Yes. Explain fully:
4.
Do you require any type of knee brace while playing or practising?
No
Yes. Explain fully:
5.
Name and address of Personal Physician.
6.
If you have consulted your Personal Physician in the last 24 months, please give date and reason for consultation.
7.
Does the Physician named in the question above also act as the physician for the team for which you play?
Yes
No
8.
Have you consulted your team physician or any other physician in the last 24 months other than for routine examination or team physical?
No
Yes. Physicians Name/Address, reasons:
Additional Comments:
1.
SECTION 3.
Have you within the last 24 months, taken any pain reducing or anti-inflammatory medication?
No
f Yes, what are you taking and how often?
2.
During the last twelve (12) months have you suffered any injury, sickness or discomfort for which you have not sought medical advice?
No
f Yes, what were the symptoms and how long did they persist?
3.
Have you been advised or do you have reason to believe that you may need medical treatment in the future?
No
Yes. Explain fully:
4.
Have you ever been advised to have treatment which has not been undertaken?
No
Yes. Explain fully:
SECTION 4.
1.
Piloting an aircraft?
No
Yes. Explain fully:
2.
Skydiving or hang-gliding?
No
Yes. Explain fully:
Do you engage in any of the following activities, or any other similar activity, which may be considered hazardous; Provide full details
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 your club contract?
No
Yes. Explain fully:
SECTION 5.
1.
Head?
No
Yes. Explain fully:
Have you ever injured or suffered pain or discomfort, or had surgery to any of the following: If yes please give details including dates.
2.
Neck (Cervical Spine)?
No
Yes. Explain fully:
3.
Right Shoulder (including Clavicle and Shoulder Blade)?
No
Yes. Explain fully:
4.
Left Shoulder (including Clavicle and Shoulder Blade)?
No
Yes. Explain fully:
5.
Chest (including ribs, sternum & diaphragm)?
No
Yes. Explain fully:
6.
Upper Back?
No
Yes. Explain fully:
7.
Lower Back (including tail bone)?
No
Yes. Explain fully:
8.
Right Hip?
No
Yes. Explain fully:
SECTION 5. (Continued)
9.
Left Hip?
No
Yes. Explain fully:
Have you ever injured or suffered pain or discomfort, or had surgery to any of the following: If yes please give details including dates.
10. Right Groin?
No
Yes. Explain fully:
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:
SECTION 5. (Continued)
17. Right Hand (including fingers and thumb)?
No
Yes. Explain fully:
Have you ever injured or suffered pain or discomfort, or had surgery to any of the following: If yes please give details including dates.
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:
22. Left Knee?
No
Yes. Explain fully:
23. Right Lower Leg?
No
Yes. Explain fully:
24. Left Lower Leg?
No
Yes. Explain fully:
SECTION 5. (Continued)
25. Right Ankle (including Achilles tendon)?
No
Yes. Explain fully:
Have you ever injured or suffered pain or discomfort, or had surgery to any of the following: If yes please give details including dates.
26. Left Ankle (including Achilles tendon)?
No
Yes. Explain fully:
27. Right Foot (including toes)?
No
Yes. Explain fully:
28. Left Foot (including toes)?
No
Yes. Explain fully:
29. Have you suffered any other injuries, discomfort or conditions to: a. Bones b. Joints c. Muscles d. Nerves 30. Have you ever undergone surgery as a result of sickness or disease or a non-injury condition? No No No No No Yes, Explain fully: Yes, Explain fully: Yes, Explain fully: Yes, Explain fully: Yes. Explain fully:
31. Have you ever undergone hospitalization or treatment as a result of sickness or disease or a non-injury condition? 32. Have you ever been advised that such surgery may be required in the future?
No
Yes. Explain fully:
No
Yes. Explain fully:
SECTION 6.
1.
Cardiac such as heart murmur, heart attack, angina, chest pain, high or low blood pressure, or any other disease of the heart or blood vessels?
No
Yes. Explain fully:
Within the last ten (10) years, have you ever shown indications of, suffered from, been treated for, or been prescribed treatment for any condition of the following:
2.
Respiratory system such as asthma, chronic bronchitis or emphysema, shortness of breath, pneumonia or any other respiratory disease?
No
Yes. Explain fully:
3.
Digestive such as ulcer, colitis, bleeding, gallbladder or liver disease or any other disorder of the stomach, intestines or rectum?
No
Yes. Explain fully:
4.
Nervous system such as paralysis, anxiety, seizures, depression or any other mental disease?
No
Yes. Explain fully:
5.
Endocrine such as diabetes, thyroid, or any other glandular disease?
No
Yes. Explain fully:
6.
Any disease of the blood?
No
Yes. Explain fully:
7.
Skin disease, cancer, cyst or tumor?
No
Yes. Explain fully:
8.
Rheumatism, arthritis, ruptured disc, or any disease, injury or deformity of the spine, joints, bones or muscles?
No
Yes. Explain fully:
SECTION 6. (Continued)
9.
Any disease of the kidneys, bladder, prostate or reproductive organs?
No
Yes. Explain fully:
Within the last ten (10) years, have 10. Any disease of the eyes, ears, you ever nose or throat? shown indications of, suffered from, been treated for, or been prescribed treatment for 11. Concussions, loss of consciousness, or any condition seizures? of the following:
No
Yes. Explain fully:
No
Yes. Explain fully (list all incidents including dates and degree of severity)
12. Paralysis whether complete or partial, regardless of length of time or duration.
No
Yes. Explain fully:
Additional Comments:
SECTION 7.
1.
Are you now, or have you ever been treated for substance or alcohol abuse?
No
Yes. Explain fully:
2.
Have you ever used marijuana, mood-altering drugs, narcotics, cocaine, heroin, barbituates, LSD or amphetamines?
No
Yes. Explain fully:
1.
SECTION 8.
Have you in the past applied for, or purchased, any additional disability coverage (i.e. accident and/or sickness)?
No
Yes. Explain fully:
2.
Has any insurance company ever applied a specific exclusion to your disability policy?
No
Yes. Explain fully:
1.
SECTION 9.
Have you ever been diagnosed or received treatment by a member of the medical profession for AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS related complex)?
No
Yes. Explain fully:
2.
Have you ever tested positive for the AIDS (HIV) virus?
No
Yes. Explain fully:
10
PLEASE READ CAREFULLY.
IT IS UNDERSTOOD AND AGREED AS FOLLOWS:
1. 2. 3. 4. 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. No agent, broker or medical examiner has authority to waive the answers to any question, to determine insurability, to waive any of the Insurers rights or requirements, or to make or alter any contract or policy. The Insurer has the right to require medical exams and tests to determine insurability. The insurance applied for will not take effect unless the health of the Proposed Insured remains as stated in the Application on the inception date of the proposed policy.
AUTHORIZATION
To all physicians, medical professionals, hospitals, clinics, other health care providers, insurers, employers, Medical Information Bureau (MIB), consumer reporting agencies, other insurance support organizations, and other persons who have information about the proposed insured. I authorize you to give the Insurer, its reinsurers, its agents (a) all information you have as to illness, injury, medical history, diagnosis, treatment, and prognosis with respect to any physical or mental condition of the proposed insured; and (b) any non-medical information, including any investigative consumer report, which the company believes it needs to perform the business functions described below. The information obtained will be used to determine if the Proposed Insured is eligible for (a) the insurance requested; or (b) benefits under a policy which is in force. It will 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 (PLEASE PRINT)
THE FOLLOWING DECLARATION IS ONLY TO BE COMPLETED WHERE A TEAM IS EFFECTING 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 full, complete and true and have been correctly recorded and we do not know of any other information which is likely to influence the decision of the Insurer and that we are willing to accept a Policy, subject to the terms and conditions of such Policy, to be issued on the basis of and in consideration of the proposal, which we understand shall be attached to and constitute a part of the Contract of Insurance.
Signature of Team Official
month day
year
Position Held
11
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:
Have you examined and/or treated this patient in the past?
YES, for NO
years
Current Vital Signs on this Examination
Height Blood Pressure Weight Pulse
Please check the appropriate box Normal Head,Eyes,Ears,Nose & Throat Skin Lungs Heart EKG Abdomen Genitalia Respiratory Circulatory Abnormal
COMMENTS
12
HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: 1. DATES: HEAD YES NO
UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED?
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality) Concussion details, if applicable.
DETAILS OF ANY SURGERY AND/OR TREATMENT
2. DATES:
NECK (Cervical Spine)
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
3. RIGHT SHOULDER,CLAVICLE,SCAPULA DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
4. LEFT SHOULDER,CLAVICLE,SCAPULA DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
5. CHEST (Including Ribs, Sternum, Diaphragm) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
13
HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: 6. UPPER BACK (Thoracic Spine) DATES: YES NO
UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED?
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
7. LOWER BACK
(Lumbar spine incl. Coccyx and Sacral Spine)
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DATES:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
8. RIGHT HIP DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
9. LEFT HIP DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
10. RIGHT GROIN DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
14
HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: 11. LEFT GROIN DATES: YES NO
UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED?
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
12. ABDOMINAL MUSCLES DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
13. RIGHT ELBOW DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
14. LEFT ELBOW DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
15. RIGHT WRIST DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
15
HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: 16. LEFT WRIST DATES: YES NO
UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED?
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
17. RIGHT HAND (Including fingers and thumb) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
18. LEFT HAND (Including fingers and thumb) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
19. RIGHT THIGH (Including hamstring) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
20. LEFT THIGH (Including hamstring) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
16
HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: 21. RIGHT KNEE DATES: YES NO
UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED?
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
22. LEFT KNEE DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
23. RIGHT LOWER LEG DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
24. LEFT LOWER LEG DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
25. RIGHT ANKLE (Including Achilles tendon) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
17
HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: 26. LEFT ANKLE (Including Achilles tendon) DATES: YES NO
UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED?
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
27. RIGHT FOOT (Including toes) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
28. LEFT FOOT (Including toes) DATES:
YES
NO
YES
NO CURRENT & FUTURE PROGNOSIS:
DETAILS: (discomfort, injury, or abnormality)
DETAILS OF ANY SURGERY AND/OR TREATMENT
ADDITIONAL COMMENTS:
18
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
19
