$2,000 Free Accidental Death coverage from BMO Life Assurance Company (BMO Insurance).

To take advantage of the offer, you must activate your coverage. Simply complete the Personal Enrolment Information (including date of birth) and sign the Activation Form.

You will be sent a Certificate of Insurance confirming your coverage.

Personal Enrolment Information

* mandatory fields

Title*

First Name*

Last Name*

Gender*

Date of Birth*

YYYY

Home Phone Number*

Unit #

Home Address*

Address cont. (optional)

City*

Province*

Postal Code*

Email Address (optional)

I consent to receiving emails from BMO Insurance regarding products and services (please read BMO Insurance's Consent to Receiving Electronic Messages).

Yes

Coverage: Free

Amount: $2,000

Beneficiary: Estate

Declaration and Signature
I declare that I am a Canadian resident between the ages of 18 and 75 and currently a BMO Bank of Montreal customer. I understand that my $2,000 FREE Accidental Insurance will begin as of the Certificate Effective Date and will end one year from that date. I have read and understand that benefits under the Plan are subject to exclusions and limitations. I understand that only accidental bodily injury sustained on or after my Certificate Effective Date and while the Certificate is in effect will be covered. I request my policy contract, including this application, be concluded in English. / Je demande que le libellé de ma police, y compris la présente proposition, soient établis en anglais.

Yes

I consent to receiving marketing information from BMO Insurance.

Yes

In order to proceed and complete this application online, you must agree to the BMO Insurance Privacy Disclosure.

Yes

Please type your full name and select “I agree” below. Typing your name and clicking the “I agree” button represents signing the application.

First Name*

Last Name*

I agree