Is the residential address the same as the mailing address?
3
Canadian Status
4
Employment Details
Are you currently employed?
5
General Information
Do you intend to travel outside of North America for longer than 2 months total, or change your Country of Residence, in the next 12 months?
In the last 2 years have you flown as a pilot, student pilot or crew member, or do you intend to in the next 12 months?
In the last 2 years have you engaged in, or do you intend to engage in any hazardous sports including: motorized racing, scuba diving, sky diving, base jumping, sky surfing, bungee jumping, hang gliding, ultra-light flying, mountain climbing, back country skiing/snowmobiling/snowboarding or Heli/Cat skiing?
Have you been charged with or convicted of driving under the influence of alcohol/drugs, or refused a breathalyzer, in the last 10 years?
Within the last 3 years have you been charged or convicted of any other driving offences (excluding parking tickets) or had your license suspended or revoked?
In the last 10 years have you been charged with, convicted of, or pleaded guilty to any criminal offence or financial services regulatory offence, or are any charges pending?
Have you smoked or used any tobacco/nicotine products or smoking cessation aids within the last 12 months?
Have you used any form of marijuana or hashish within the last 5 years?
Have you ever used unprescribed drugs or experimented with drugs such as ecstasy, cocaine, LSD, heroin, amphetamines, barbiturates, anabolic steroids or similar?
Do you drink alcohol?
Have you ever been treated or counselled for alcohol abuse, or has someone recommended you seek such treatment?
6
Financial Information
Have you ever declared bankruptcy or had major financial difficulties (garnished wages, consumer proposal, pending bankruptcy petition), whether discharged or not?
7
Insurance History
Do you have any other insurance in force?
Have you ever had any application for life, disability, critical illness or long term care insurance declined, rated, postponed, offered with restrictions, cancelled or modified in any way?
Do you have an application for life, disability, critical illness or long term care insurance currently pending with any other company?
8
Temporary Life Insurance Request
Would you like to request Temporary Life Insurance?
Temporary Insurance Health Questions
Have you ever been treated for or had any known indication of stroke, chest pain, cancer, tumours, chronic kidney or liver disease?
Have you ever been treated for or had any known indication of AIDS, ARC or any other immunological disorder?
Have you, within the last 90 days, been admitted to a medical facility, advised to be admitted, or had a diagnostic test/surgery recommended or performed (other than normal childbirth)?
Have you ever had an application for Life or Critical Illness insurance declined, postponed, rated or modified?
Have you, within the last 12 months, been absent from work or unable to perform regular daily activities for 15 or more consecutive days due to illness or injury?
Have you ever been treated for or had any known indication of heart or blood vessel disease, not including high blood pressure?
9
Beneficiaries
Primary Beneficiary
Primary 1
Contingent Beneficiary
Contingent 1
10
Payor / Banking Information
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