Motor Racing Questionnaire

Name (first, middle initial, last) Date of birth (d/m/y) Policy no. ______- __ Advisor’s name Advisor’s no.

1 | Automobile racing Types(s) of racing engaged in: Auto crash: T-bone, Rollover, Dive Bomber, etc. Kart Enduro, Sprint Demolition Derby Experimental, others Grand Touring (including Trans-Am Midget/Sprint car: 1/4, 1/2 and IROC) 3/4 Full (Outlaw) Record attempts IMSA GT Drag Racer: Top Fuel Dragster, Funny Car, Prostock (PRO) Indy Light Car Other or Amateur Vintage or other sports car racing Off-Road (Baja 500, Mexican 1000, etc.) Rally: Professional Stock car (Specify type) Other or amateur Record Attempts Sedan Racing (BMW, Audi, etc.) Jet Car: Exhibition Time trials Record attempts Pleasure or Income

Sports Cars: Can-Am Professional Training Yes No Other ______ Formula car (Specify type):

Make(s), model(s) and engine size(s) of vehicles(s): ______

______2 | Motorcycle racing Types(s) of racing engaged in: Drag Racer: Top Fuel Road racing (Grandprix or Productions): Stunt riding, acrobats, daredevils, Modified Street or stock Engine size: ______cc time trials or speed record attempts Make and model: ______Professional Training Yes No Pleasure or Motorcross: Income Engine size: ______cc Make and model: ______ Speedways (Ovals): Other ______Engine size: ______cc Make and model: ______3 | Powerboat racing Types(s) of racing engaged in: (check the boxes that apply) Stock Offshore racing Other 4 | Complete in all cases Where do you race? What type(s) of surface(s) do you race on? What type(s) of course(s) do you race on?

How often do you race? Last 12 months? Next 12 months? Name of Sanctioning body

Declaration: I declare that the answers and statements to the above questions are full, complete and true and shall form part of my appli- cation for insurance on my life with the Sun Life Assurance Company of Canada. I understand that if I do not fully, completely and truth- fully answer the above questions (if I misrepresent my answers or statements) the Company may void the policy.

Signature of Insured person Date (d/m/y) X The product you are applying for is issued by Sun Life Assurance Company of Canada

E19-06-05 Please send fax or original.