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  ON LINE APPLICATION FORM.

This is an Application for a single Life, Term Life Insurance Policy. Please fill out the application form below. We will email you your quotation along with instructions of the application process and any additional forms that are required. Please complete the below form with all of your details and when complete, click on the submit button. All fields are required. Put N/A (Not Applicable) if the questions do not apply.

First Name:
Initials:
Last Name:
Address:
Postcode:
Cell or Home Phone: (We need to call you to confirm your submission, Please put in a # that is accessible)
Email:
Age:
DOB (dd/mmm/yyyy): i.e (16/Jan/1968)
Are you in Good Health? Yes No
Have you Smoked in the last 12 months? Yes No
Gender: Male Female
Language: English French
Are you a resident for Income Tax Purposes? Yes No
What is your Citizenship?
Coverage Required:
Coverage Amount Required? (minimum is $100,000) $
Occupation
Employer
How long with employer
Type Of Business
Annual Income $
Net Worth $
Main Beneficiary
Has any Application, including any request to reactivate / reinstate any life insurance, Critical Illness, Long term Care, or Disability Insurance ever been declined, rated, postponed, cancelled, recinded or modified in any way? Yes No
Do you have any other Life Insurance with any other company? Yes No
If yes... What company?
Is this Insurance you are applying for intended to replace another Insurance companies Policy? Yes No
Have you applied to another Life insurance Company in the last 6 months or do you have another application pending? Yes No
If yes... What company?
Have you within the last 5 years flown as a pilot, Student pilot, crew member or do you intend to do so? Yes No
Have you in the last 5 years participated in Motor Vehicle racing, Motor Boat racing, Scuba Diving, Skin Diving, Sky Diving, Hand Gliding, Ultra Light Flying, Hot Air Ballooning, Mountaineering, Heli Skiing, or any other similar sport or avocation? Yes No
If yes... What avocation? (We will send you a suplimentary questionnaire)
Have you travelled, resided or worked outside North America in the last 12 Months or do you intend to do so in the next 12 months? Yes No
If yes... Please include countries visited, dates and length of time abroad
Have you had more than TWO moving violations in the past 3 years? Yes No
If yes... Please give details
Have you had a license suspension, DUI or reckless drivin conviction in the last 5 years? Yes No
If yes... Please give details
Have you had a license suspension, DUI or reckless drivin conviction in the last 10 years? Yes No
If yes... Please give details
Have you been charged or convicted of a criminal offence? Yes No
Have you declared Corporate or Personal Bankruptcy in the last 3 years that has not been discharged? Yes No
If yes... Please give dates
Mode of Payment once approved. (Monthly, Semi Annually, Annually or 1st Annual Premium on Credit Card)