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Key Person Failure to Survive Application Form

To apply for "Key Person Failure to Survive" coverage, please complete the form below.

Proposed Insured Person Insurability

This section must be completed by the proposed insured person.

If “Yes” is answered for any of the following questions, please provide full details in the space below.

Financial Insurability

Please provide a breakdown of how you will suffer a financial loss in the event of death of the Key Person along with any supporting financial documentation:

Declaration (The Applicant must read this before signing)

I am aware that the policy wording contains exclusions in coverage in respect of AIDS, HIV, suicide, alcohol and drugs. To the best of my knowledge and belief the information provided in connection with this application, whether in my own hand or not, is true and I have not withheld any material fact. I understand that non-disclo- sure or misrepresentation of a material fact will entitle underwriters to void this insurance. (A material fact is one likely to influence acceptance or assessment of this application by underwriters.