Please Complete All Field Areas
Contact Information:
Name:
E-Mail Address:
Home Tel: (###-###-####) Work Tel:
Addr: Line 1 (number & street name)
Line 2 (city, province, postal code)
Current Life Insurance Information:
Do you currently own life insurance? Yes No,
If "No", Have you owned life insurance in the past?Yes No
Present Insurer (example: Sun Life)
Life Applicant #1 Info:
Your name: D.O.B. (yyyy/mm/dd)
Male Female Married/Common-Law Single
Have you smoked cigarettes/cigars/pipe in the past 12 months? Yes No
Please select amount of insurance required:
Please let me know your reason for needing insurance:
Life Applicant #2 Info:
Your name: D.O.B. (yyyy/mm/dd)
Male Female Married/Common-Law Single
Have you smoked cigarettes/cigars/pipe in the past 12 months? Yes No
Please select amount of insurance required:
Please let me know your reason for needing insurance:
Life Applicant #3 Info:
Your name: D.O.B. (yyyy/mm/dd)
Male Female Married/Common-Law Single
Have you smoked cigarettes/cigars/pipe in the past 12 months? Yes No
Please select amount of insurance required:
Please let me know your reason for needing insurance:
Any additional comments?
