Accidental Death & Dismemberment Conversion Package

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1 Accidental Death & Dismemberment Conversion Package

2 Accidental Death & Dismemberment Conversion Package Converting your Accidental Death & Dismemberment Coverage from the Group Policy to an Individual Policy Act now to avoid an interruption of coverage This brochure sets forth the conditions under which a person no longer eligible for insurance under the ACE INA Life Insurance Group Policy may convert to an individual policy affording Accidental Death and Dismemberment benefits. How to Apply Complete the enclosed application. Write a cheque (payable to ACE INA Life Insurance) for the initial premium. Send the application and cheque to: ACE INA Life Insurance York Street, Toronto, Ontario M5J 2V5

3 Application for Conversion to Individual Policy of Accidental Death and Dismemberment Insurance This part of the Application to be completed by Employer Master Policy or Reference Number: Name of insured employee or of employee s insured dependent: On the above person terminated employment or otherwise (date) became ineligible for coverage under the Group Accidental Death and Dismemberment policy underwritten by ACE INA Life Insurance. Prior to that date the above individual was insured for $. The individual s dependent family members: were included. were not included. Family Plan (insert Percentage if applicable) Employee 100% of Principal Sum Spouse % of Principal Sum (if NO children) % of Principal Sum (if children) Each child % of Principal Sum % of Principal Sum (if NO spouse) Signed: Date: Title: For: Address: Organization Street Number and Street City Province Postal Code

4 Application for Conversion to Individual Policy of Accidental Death and Dismemberment Insurance This part of the Application to be completed by the Proposed Insured Application is hereby made for conversion to an individual Accidental Death and Dismemberment Insurance Policy. Proposed Insured: Full Name: Address: Date of Birth: Former Occupation: Present Occupation: Present Employer (if any): I desire to convert $ of my employee Accidental Death and Dismemberment insurance policy. Print full name of beneficiary and state relationship to you: Family Plan: Accidental Death and Dismemberment Insurance is to be converted for the amounts shown below: Name Amount Date of Birth Beneficiary & Relationship Present Occupation* Spouse: *Complete present occupation if person is over 18 My cheque (made out to ACE INA Life Insurance) in the amount of $ is enclosed. Application and initial premium payment must be mailed within 31 days of eligibility to convert. I have read the above statements and agree that they are accurate and complete to the best of my knowledge and belief. I understand that this insurance will be issued in reliance upon such statements. Signature of Proposed Insured/Policyowner: Date:

5 Who may Convert? You may elect to convert all or part of your Accidental Death and Dismemberment benefit, subject to a minimum of $25,000 and a maximum of $200,000. You may also convert your dependents AD&D benefits when group insurance terminates because of: Termination of employment: Termination of your dependent s eligibility for any reason (except for age or termination of the group plan under which you are insured); Provided you apply within 31 days after your group insurance terminates and pay the premium for the new policy at the rate then in effect for your attained age and occupation. Medical certification or evidence is not required. The Converted Policy Will be effective on the date of your application, but no earlier that the date on which your group coverage terminated. If injuries result in death or dismemberment within one year of the date of the accident, the policy will pay as follows: For Loss of: Percentage of the Principal Sum: Life 100% of the Principal Sum Both hands, or both feet, or entire 100% of the Principal Sum sight of both eyes, or one hand and one foot, or sight of one eye and either one hand or one foot, or loss of speech and hearing in both ears Quadriplegia, or paraplegia, or 100% of the Principal Sum hemiplegia One arm or one leg 75% of the Principal Sum One hand, or one foot, or sight in one 66 2/3% of the Principal Sum eye, or loss of speech, or hearing in both ears Thumb and index finger of same hand 33 1/3% of the Principal Sum Only one amount, the largest to which you are entitled, is paid for all losses resulting from the accident. Does not pay for loss if caused by intentionally selfinflicted injuries; suicide; act of war; or loss resulting from accident occurring while serving full-time duty in the Armed Forces (premium pro-rated and returned for such period). Air travel coverage is included, as a passenger only in any plane, including military air transport aircraft, excluding any other military planes and planes being used for testing. Policy renewable with Company consent until age 70. The company may change renewal premium rates only on a class basis, not on an individual basis. You may cancel your policy at any time after its initial term. If you were insured under more than one group AD&D contract written by the Company with your present employer, you may apply to convert each, but a separate application must be completed for each conversion.

6 Selection of Principal sum Conversion You may convert to an individual Accidental Death and Dismemberment policy from a minimum of $25,000 each policy to a maximum of the amount for which you were insured, if over $25,000, under the group plan, or $200,000, whichever is less. If the amount for which you were insured under the group plan appears in the chart below, you may select that amount as your maximum. If your previous amount does not appear, your maximum would be the higher figure appearing below. As an example: if you were insured for $55,000, you may convert for any amount in even thousands ($1000s) from a $25,000 minimum to a maximum of $60,000. The premiums listed are for annual premium payments. The minimum premium payment per policy is $ The premium rates shown here are for persons in Class 1 occupations; these are individuals engaged in occupations such as executives, managers, salesmen, accountants, lawyers, teachers, administrators and similar occupations. If your new occupation is other than Class 1, the Company will inform you of the rates which apply upon receipt of your conversion application. Class 1 Annual Premium If you are now age: Principal Sum $25,000 $50.00 $55.00 $87.50 $30,000 $50.00 $66.00 $ $40,000 $50.00 $88.00 $ $50,000 $60.00 $ $ $60,000 $72.00 $ $ $70,000 $84.00 $ $ $80,000 $96.00 $ $ $90,000 $ $ $ $100,000 $ $ $ $110,000 $ $ $ $120,000 $ $ $ $130,000 $ $ $ $140,000 $ $ $ $150,000 $ $ $ $160,000 $ $ $ $170,000 $ $ $ $180,000 $ $ $ $190,000 $ $ $ $200,000 $ $ $ ACE INA Insurance ACE INA Life Insurance York Street, Toronto, Ontario M5J 2V Main Fax

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