SPORTS APPLICATION FORM AND MEDICAL EXAMINER S REPORT

Transcription

1 SPORTS APPLICATION FORM AND MEDICAL EXAMINER S 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 EXAMINER S 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.

2 Suite Yonge Street Toronto, Ontario M5E 1S9 (416) Fax: Website: Insurance effected through PART 1 - APPLICATION FORM ALL QUESTIONS MUST BE ANSWERED IN INK. SECTION Name in full 2. Address TO BE COMPLETED BY APPLICANT 3. Birth Sex M F Date month day year weight height 4. Sport 5. Name of team Professional Collegian Other 6. Position 7. Do you have any other employment full or part-time? Yes No If Yes, describe QUESTIONS 8-14 ARE NOT APPLICABLE IF COLLEGIATE STATUS 8. Employer 9. Address 10. Nature of Employer s 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 1

3 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 Are you currently free Yes No. Explain fully: of injury, illness or discomfort? 2. Are you currently physically able Yes No. Explain fully: to perform all of the duties required in your sport as stated in Section 1 of the Application Form? 3. Have you missed any playing time No Yes. Explain fully: during the last 24 months as a result of injury, illness, discomfort or for any other reason? 4. Do you require any type of knee brace No Yes. Explain fully: while playing or practising? 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 Yes No question above also act as the physician for the team for which you play? 8. Have you consulted your team No Yes. Physician s Name/Address, reasons: physician or any other physician in the last 24 months other than for routine examination or team physical? Additional Comments: 2

4 SECTION Have you within the last 24 months, No If Yes, what are you taking and how often? taken any pain reducing or anti-inflammatory medication? 2. During the last twelve (12) months No If Yes, what were the symptoms and how long have you suffered any injury, sickness did they persist? or discomfort for which you have not sought medical advice? 3. Have you been advised or do you No Yes. Explain fully: have reason to believe that you may need medical treatment in the future? 4. Have you ever been advised to No Yes. Explain fully: have treatment which has not been undertaken? SECTION 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 No Yes. Explain fully: your club contract? 3

5 SECTION 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 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 Hip? No Yes. Explain fully: 4

6 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: 10. Right Groin? No Yes. Explain fully: 11. Left Groin? No Yes. Explain fully: If yes please give details including dates. 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: 5

7 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: 6

8 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 No Yes, Explain fully: b. Joints No Yes, Explain fully: c. Muscles No Yes, Explain fully: d. Nerves No Yes, Explain fully: 30. Have you ever undergone surgery No Yes. Explain fully: as a result of sickness or disease or a non-injury condition? 31. Have you ever undergone No Yes. Explain fully: hospitalization or treatment as a result of sickness or disease or a non-injury condition? 32. Have you ever been advised that No Yes. Explain fully: such surgery may be required in the future? 7

9 SECTION Cardiac such as heart murmur, heart No Yes. Explain fully: attack, angina, chest pain, high or low blood pressure, or any other disease of the heart or blood vessels? 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, No Yes. Explain fully: chronic bronchitis or emphysema, shortness of breath, pneumonia or any other respiratory disease? 3. Digestive such as ulcer, colitis, No Yes. Explain fully: bleeding, gallbladder or liver disease or any other disorder of the stomach, intestines or rectum? 4. Nervous system such as No Yes. Explain fully: paralysis, anxiety, seizures, depression or any other mental disease? 5. Endocrine such as diabetes, No Yes. Explain fully: thyroid, or any other glandular disease? 6. Any disease of the blood? No Yes. Explain fully: 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 the spine, joints, bones or muscles? 8

10 SECTION 6. (Continued) 9. Any disease of the kidneys, No Yes. Explain fully: bladder, prostate or reproductive organs? 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: 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 dates consciousness, or and degree of severity) seizures? 12. Paralysis whether complete No Yes. Explain fully: or partial, regardless of length of time or duration. Additional Comments: 9

11 SECTION Are you now, or have you ever been No Yes. Explain fully: treated for substance or alcohol abuse? 2. Have you ever used marijuana, No Yes. Explain fully: mood-altering drugs, narcotics, cocaine, heroin, barbituates, LSD or amphetamines? SECTION Have you in the past applied for, No Yes. Explain fully: or purchased, any additional disability coverage (i.e. accident and/or sickness)? 2. Has any insurance company ever No Yes. Explain fully: applied a specific exclusion to your disability policy? SECTION Have you ever been diagnosed or No Yes. Explain fully: received treatment by a member of the medical profession for AIDS (Acquired Immune Deficiency Syndrome) or ARC (AIDS related complex)? 2. Have you ever tested positive for the No Yes. Explain fully: AIDS (HIV) virus? 10

12 PLEASE READ CAREFULLY. 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 of the Insurer s 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 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

13 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 years NO Current Vital Signs on this Examination Height Blood Pressure Weight Pulse Please check the appropriate box Normal Head,Eyes,Ears,Nose & Throat Abnormal COMMENTS Skin Lungs Heart EKG Abdomen Genitalia Respiratory Circulatory 12

14 HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED? 1. HEAD YES NO YES NO Concussion details, if applicable. 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 13

15 HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED? 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 10. RIGHT GROIN YES NO YES NO 14

16 HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED? 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 15

17 HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED? 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 16

18 HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED? 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 17

19 HAS THE PROPOSED INSURED SUFFERED DISCOMFORT, INJURY OR REQUIRED TREATMENT TO ANY OF THE FOLLOWING: UPON EXAMINATION WERE THERE ANY ABNORMALITIES IDENTIFIED? 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: 18

20 On completion of physical examination, please provide your overall impression with regard to player s 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 EXAMINER S SIGNATURE APPLICANT S SIGNATURE EXAMINER S NAME APPLICANT S FULL NAME EXAMINER S ADDRESS TELEPHONE NUMBER FAX NUMBER ANY ADDITIONAL COMMENTS 19