Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone

(###)

###

####

Marital Status

Single

Married

Smoking Status *

Smoker

Non-Smoker

If non-smoker was selected, check off the following:

I have not smoked any tobacco products in the last 12 months.

1. Do you currently have any Life, Critical Illness or Disability Insurance in force?

Check all that Apply:

Life Insurance

Critical Insurance

Disability Insurance

2. Do you currently have a mortgage?

Yes; and I need Mortgage Insurance

Yes; and I already have Mortgage Insurance

No; But I'm planning to purchase soon

No

3. Do you understand the difference between Mortgage Insurance and Personal Life Insurance?

Yes

I think so

No

4. Do you have children?

Yes: 1

Yes: 2

Yes: 3+

No

5. If an unexpected tragedy took place (death, critical illness, or disability diagnosis): Do you have the proper protection in place already for you and your family?

Check all that apply:

Life Insurance

Critical Illness

Disability

Other

6. If you are unable to work due to an unforeseen injury or illness: How many months could you and your family survive and continue your lifestyle without any income?

0-1 Month

1-2 Months

3 Months

4+ Months

7. Would you like to receive money should you survive a critical Illness diagnosis?

**63% of Canadians diagnosed with cancer are expected to survive. Almost 77% of Canadians who have a heart attack will survive. Lastly, about 72% of Canadians who have a stroke survive. Check all that apply:

Yes: I would like to receive money to supplement a year (or more) off work

Yes: I would like to receive money to help my healing process

Yes: I would like to receive money to spend more time with and take care of my family

No

8. If you suddenly passed away, how much money would your family need to cover funeral costs, pay off all outstanding debts / expenses and still leave an income to continue on?

$100,000

$250,000

$500,000

$1 Million

Other