Motor Racing Questionnaire

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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: २ T-bone, Rollover, Dive Bomber, etc. Kart २ Enduro, Sprint २ Demolition Derby २ Experimental, others २ Grand Touring (including Trans-Am Midget/Sprint car: २ 1/4, 1/2 and IROC) २ 3/4 Full (Outlaw) २ Record attempts २ IMSA GT Drag Racer: २ Top Fuel Dragster, Funny Car, Prostock (PRO) २ Indy Light Car २ Other or Amateur २ Vintage or other sports car racing २ Off-Road (Baja 500, Mexican 1000, etc.) Rally: २ Professional २ Stock car (Specify type) २ Other or amateur Record Attempts २ Sedan Racing (BMW, Audi, etc.) Jet Car: २ Exhibition २ Time trials २ Record attempts २ Pleasure or Income Sports Cars: २ Can-Am Professional Training २ Yes No Other _________________ २ Formula car (Specify type): Make(s), model(s) and engine size(s) of vehicles(s): _____________________________________________________________________________ ______________________________________________________________________________________________________________________________2 | Motorcycle racing Types(s) of racing engaged in: २ Drag Racer: २ Top Fuel २ Road racing (Grandprix or Productions): २ Stunt riding, acrobats, daredevils, २ Modified २ Street or stock Engine size: _____________ cc time trials or speed record attempts Make and model: _____________ _____________________________ Professional Training २ Yes २ No २ Pleasure or २ Motorcross: २ Income Engine size: ___________ cc Make and model: _______________ _______________________________ २ Speedways (Ovals): Other ____________________________ Engine size: ___________ cc Make and model: _______________ _______________________________ 3 | Powerboat racing Types(s) of racing engaged in: (check the boxes that apply) २ Stock २ Offshore racing २ 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..

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