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The Right Insurance
The Right Reasons
The Right Price
Proposed Life Insured:
Date of Birth (m/d/y)
Place of Birth
Years in Canada
Employment & Contact Information:
Bus. Phone No.
Home Phone No.
Life Insurance in Force:
Do you have any Life Insurance in force?
In the past 24 months, have you used any form of nicotine, marijuana, nicotine product or nicotine substitute?
Has any company declined to issue, reinstate or renew, rated, modified, postponed or cancelled any insurance on your life?
Is this insurance intended to, or will it in fact, replace, or will it cause a change in, or involve a loan under any insurance or annuity policy?
Within the last 6 months have you applied for life or health insurance with any insurance carrier?
Have you ever applied for or received a pension, disability benefit or any other compensation because of illness of injury?
Have you ever experienced high blood pressure, heart attacks, angina, cancer, diabetes, stroke, epilepsy or mental disorders?
Have you taken any flights in the past 24 months, or do you intend to take any flights, other than as a fare-paying passenger on a commercial airline?
Have you engaged in any hazardous sports (including, but not limited to, motorized vehicle racing, scuba or sky diving, parachuting, hang gliding, mountain climbing) in the past 10 years or do you intend to do so within the next 24 months?
Have you been convicted of, have pending charges for, or pleaded guilty to any moving violations or had any traffic accidents or any reckless driving violations within the past 5 years?
Have you been convicted of, have pending charges for, or pleaded guilty to driving under the influence of alcohol and/or drugs, or refused to provide a breathalizer sample within the past 10 years?
Have you travelled or resided outside of Canada and the United States in the past 12 months or do you intend to in the next 12 months?
Have you ever declared bankruptcy, personal or business, whether discharged or not?
Have you ever been charged or convicted of any criminal offence, or have any criminal charges pending?
Are you acting on behalf of a third party on a proposed life insurance policy?
Please provide details to any of the above questions that were answered ‘Yes’
Life Insurance Applied For:
10 Year Term
20 Year Term
Term to 100
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