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Proposed Life Insured:

 
 
 
      Last Name   First Name   Initial
 

Demographic Information:

 
 
 
 
 
 
 

Date of Birth (d/m/y)

  

Place of Birth

 

 

 
 
 
 
 
 
  Marital Status   Former/Maiden Name   Canadian Status  
 

Employment & Contact Information:

 
 
 

Employer

 

Occupation

 

Website

 
 

Bus. Address

Home Address

 

 

 

 

 

 

   

 

 
 

Bus. Phone No

Home Phone No

 
 

Email Address

 

Mailing Address:

 
Business Address     Home Address
 

Beneficiary:

 

Full Name  

Relationship  

Share (%)

 
 

 
 

 

 

 
 

Life Insurance in Force:

 
 
Do you have any Life Insurance in force? Yes    No
 
 

Carrier

Date Issued

Amount

Premium

 

 

Personal Information:

 
  In the past 24 months, have you used any form of nicotine, marijuana, nicotine product or nicotine substitute?  
Yes  No
 
  Has any company declined to issue, reinstate or renew, rated, modified, postponed or cancelled any insurance on your life?  
Yes  No
 
  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?  
Yes  No
 
  Within the last 6 months have you applied for life or health insurance with any insurance carrier?  
Yes  No
 
  Have you ever applied for or received a pension, disability benefit or any other compensation because of illness of injury?  
Yes  No
 
  Have you ever experienced high blood pressure, heart attacks, angina, cancer, diabetes, stroke, epilepsy or mental disorders?  
Yes  No

Please provide details to any of the above questions that were answered 'Yes'

 
 

 
 

Net Income

Unearned Income

Net Worth

 
 

Life Insurance Applied For:

 
 
 
 

 


Privacy Notice

The President’s Group Insurance Agency Inc.("TPG"), in coordination with its associates, must collect, use and disclose your personal information for the express purpose of providing you with the products and services you request.
Your personal information includes contact information, date of birth, and health, lifestyle, family and financial information, all of which is needed to apply for insurance with the various life insurance companies that we represent. In addition, this information is needed to administer your insurance and investment products in compliance with regulatory requirements.
TPG discloses this information to life insurance companies on your behalf as part of the application process. In addition, TPG discloses limited personal information to paramedical companies and to investigative agencies, but only to the extent that is necessary to arrange for the services that they perform on behalf of life insurance companies. These organizations are bound by and must comply with federal and provincial privacy legislation.
TPG does not disclose your information to any other organizations to use for their own purposes and, in particular, will never sell or trade your personal information. From time to time, TPG may use your personal information to determine which other insurance and financial products may meet your needs and to offer them to you. If you do not wish to receive these offers, please write to us at the address below.
The personal information that TPG collects, uses and discloses is essential to our being able to provide you with products and services. Therefore, we consider that, by requesting or buying our products and services, you have consented to our collecting, using and disclosing your personal information.
Only those TPG employees, agents and authorized service providers who need your personal information to do their jobs are given access to your personal information. We make every effort to ensure that the personal information collected and used is accurate and, where necessary, updated. You have the right to request correction of any inaccurate or incomplete information about you in our possession.
If you wish to review or make changes to your file, you may do so by making a written request to the address below. If you have any questions or concerns regarding the use of your personal information or the content of this document, we encourage you to speak with your advisor. Alternatively, you may contact our Privacy Officer at the address below, or fax 416-946-1446.

Privacy Officer
The President’s Group Insurance Agency Inc.
3660 Hurontario Street, 10th Floor
Mississauga, Ontario L5B 3C4
1-800-661-7066

 

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© 2007 The President's Group Life Insurance Agency Inc. All rights reserved.