Home
Blog
Solutions
Insurance
No Medical Life Insurance
Term Life Insurance
Permanent Life Insurance
Final Expenses
Living Benefits
Critical Illness
Disability
Health & Dental
Long Term Care
Travel Insurance
Investments
RRSP, TSFA, RRIF, LIF & LIRA
RESP Education Funding
Annuities
Group Pension Plans
About
Contact Us
Home
Blog
Solutions
Insurance
No Medical Life Insurance
Term Life Insurance
Permanent Life Insurance
Final Expenses
Living Benefits
Critical Illness
Disability
Health & Dental
Long Term Care
Travel Insurance
Investments
RRSP, TSFA, RRIF, LIF & LIRA
RESP Education Funding
Annuities
Group Pension Plans
About
Contact Us
Home
Blog
Living Benefits
Insurance
Investments
About
Contact Us
Linkedin
Facebook
Twitter
Protect What Matters
Coverage Application
Step
1
of
9
11%
X/Twitter
This field is for validation purposes and should be left unchanged.
What is your primary concern for getting this coverage?
*
Protecting your paycheque
Protecting your family's lifestyle
Protection against critical illness
Protection against unexpected
Name
*
First
Last
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Permanent Resident of Canada
*
Yes
No
Gender
*
Male
Female
Date of Birth
*
Age
*
Height (ft/in)
*
Weight (lbs)
*
Occupation
*
Identification Card Provided
*
Driver's License
Passport
Permanent Resident Card
Canadian Citizenship Card
Identification Card #
*
Issuing Jurisdiction
*
Date of Issue
*
Expiry Date
HEALTH QUESTIONS
Within the past 12 months, have you used any form of tobacco product (including cigarettes, electronic cigarettes, cigars, cigarillos, pipes, snuff/chew/dip, nicotine patch or nicotine gum)?
*
Yes
No
Have you or any eligible dependents received any medical advice (including referrals to other Physicians for diagnostic tests and surgery) or treatment from a member of the medical profession, or taken any prescription medication within the past five (5) years for cancer, or any malignant growth, including Leukemia and Hodgkin’s disease?
*
Yes
No
Have you ever had any positive test, treatment for or exposure to Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) or AIDS Related Complex (ARC)?
*
Yes
No
Have two (2) or more of your parents, brothers or sisters been diagnosed with cancer, or any malignant growth (other than skin cancer which is not malignant melanoma), including Leukemia and Hodgkin’s disease while they were under the age of 60?
*
Yes
No
Have you or any eligible dependents received any medical Advice (including referrals to other Physicians for diagnostic tests and surgery) or Treatment from a member of the medical profession, or taken any prescription medication within the past five (5) years for: a. Angina, stroke, brain tumour, transient ischemic attack (TIA), traumatic head injury, heart attack, atrial fibrillation, congestive heart failure, coronary artery disease, or a heart valve replacement?
*
Yes
No
b. Any chronic or progressive disease or disorder of the kidney, lung, liver, pancreas or bone marrow that may lead to the failure of the organ or that may require transplantation?
*
Yes
No
c. Chronic obstructive Lung/Pulmonary disease, emphysema or other lung disease requiring oxygen?
*
Yes
No
d. Alcoholism or drug addiction?
*
Yes
No
e. Dementia, Parkinson’s disease, multiple sclerosis, Amyotrophic Lateral sclerosis (Lou Gehrig’s disease), or muscular dystrophy?
*
Yes
No
Do you have two (2) or more of your parents, brothers or sisters been diagnosed with heart disease while they were under the age of 60?
*
Yes
No
BENEFICIARY INFORMATION:
Primary Beneficiary First Name
*
Primary Beneficiary Last Name
*
Check if beneficiary is a minor
Check if beneficiary is a minor
A minor is a child who has not reached the age of majority as defined by provincial legislation.
Gender
*
Male
Female
Relationship to the Primary Beneficiary
*
Married Spouse / Civil Union
Common Law Spouse
Child
Father
Mother
Brother
Sister
Aunt
Uncle
Cousin
Dependent
Friend
Grandfather
Grandmother
Guardian
Other
Parent
Street Address
*
City
*
Postal Code
*
Province
*
Additional Notes
Use this field to enter any important information as needed for any additional primary beneficiaries.
Trustee Name for Primary Beneficiary
Any payment becoming due while the beneficiary is a minor are to be made to the name provided in this field as trustee. If no trustee is named, the payment will be made in accordance with the applicable Provincial & Federal laws of Canada, and may need to be paid in court.
Check to add a Contingent Beneficiary
Check to add a Contingent Beneficiary
Contingent Beneficiary First Name
Contingent Beneficiary Last Name
Check if contingent beneficiary is a minor
Check if contingent beneficiary is a minor
A minor is a child who has not reached the age of majority as defined by provincial legislation.
Gender
Male
Female
Relationship to the Contingent Beneficiary
Married Spouse / Civil Union
Common Law Spouse
Child
Father
Mother
Brother
Sister
Aunt
Uncle
Cousin
Dependent
Friend
Grandfather
Grandmother
Guardian
Other
Parent
Contingent Beneficiary Street Address
Contingent Beneficiary City
Contingent Beneficiary Postal Code
Contingent Beneficiary Province
Trustee Name for Contingent Beneficiary
Any payment becoming due while the beneficiary is a minor are to be made to the name provided in this field as trustee. If no trustee is named, the payment will be made in accordance with the applicable Provincial & Federal laws of Canada, and may need to be paid in court.
Additional Notes for Contingent Beneficiary
Use this field to enter any important information as needed for any additional contingent beneficiaries.
FINANCIAL INFO:
Please provide an estimated value for your personal financial information in the section below. Rest assured, all the information you provide is secure and confidential, and will only be used to process your application.
Est. Monthly Gross Income
*
Est. Monthly Net Income
*
Are you a Home Owner?
*
Yes
No
Estimated value of your home
*
Est. Mortgage Balance
*
Est. value of your RRSPs, RRPs, RRIFs?
*
Est. value of Other Assets?
*
Est. value of your Savings?
*
Est. total of any other debts?
*
Est. total credit card debt?
*
PAYMENT DETAILS:
Bank Name
*
Bank Street Address
*
City
*
Province
*
Bank Transit Number
*
Bank Institution Number
*
Bank Account Number
*
Preferred Billing Date
What day of the month would you prefer to be billed on?
I would like to receive my policy and related documents digitally.
*
Yes
No
