Accident Policy Fact Finder
Accident Insurance pays cash benefits when a covered accidental injury occurs. If you have an accident, you can use the cash benefits to pay medical bills and other expenses while you’re unable to work.
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Do you use Tobacco?
*
Yes
No
If "Yes" for Tobacco, when was your last usage?
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Month
-
Day
Year
Date
Name of Beneficiary
First Name
Last Name
Beneficiary's Relationship to You
Please list anyone else that will be covered under this Accident Plan.
Applicant #2
Date of Birth for Applicant #2
-
Month
-
Day
Year
Date
Applicant #3
Date of Birth for Applicant #3
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Submit
Should be Empty: