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Quotation Request form (Step 1)
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General Information About Proposed Insured
First Name E-mail
Last Name Best Time to Call
Address Birthday(Y/M/D)
City Gender Male  Female
Province Height(Ft/In)
Postal Code Weight(lbs)
Area Code
& Telephone
Last Used Tobacco
Any Foreign Travel Planned?
(Destinations & length of time)

Personal Health & Family History Of Propos
Yes No
Ever been on medication for Blood Pressure?
Ever been on medication for High Cholesterol?
Ever had a history of Alcoho or Drug abuse?
Do you Fly, other than as a fare paying passenger?
Ever been charged with DUI?
Had more than 3 moving violations in last 3 years?
Involved in a Hazardous occupation or Avocations?
Any incidents, of your Parents or Siblings, prior to age 60
Having: Cancer; Stroke, Heart Attack or Heart Disease or Diabetes?
(Indicate number, type and ages(s) of diagnosis of each.)

Indicate the type of insurance you're interested in and complete the information for that product

Critical Illness Insurance
$ Critical Illness (Ages 20 - 65)
Lump sume Benefit ($25,000 - $2,000,000)
Plan Type
1. 10 Year Renewable
2. Level (To Age 70/75)
3. Level & Paid-Up at Age 65
4. Permanent (Level to Age 100)
5. Comprehensive Critical Illness (C.I. & LTC)
Return of Premiums at Death
Return of Premiums at Expiry
Comprehensive Critical Care

Life Insurance
$ Amount (Ages 18 - 65)
Quote Type
Single Life
Multi-Lives (# )
Joint & First To Die
Joint & Last To Die (Premium to 2nd death)
Joint & Last To Die (Premium to 1st death)
Plan Type
Term 10
Term 20
Term 100
Term 100 + values
Life Paid-up at Age 65
20 Pay Life
10 Pay Life

For a Joint Quote
Information Required About 2nd Life:
Gender Male  Female
Smoking Status Yes  no
Height(Ft/In) / Weight(lbs) /

LTC (Long Term Care) Insurance
$ LTC (Ages 20 - 80)
Daily Benefit ($10 - $300)
Home Care     Facility Care
Benefit Payment Period
Lifttime    5 Years
2 Years     Other
Elimination or Waiting Period Days
30   60
90     Other
Future Purchase Option
Cost of Living Adjustment  

LTD (Long Term Disability) Insurance
Earned Income $
Basic Coverage
Amount:   $
Taxable Benefit     E.I.
Self Employed    
Accident & Sickness   Accident Only
Waiting Period in Days
30   60
90     120
14 Days (for Accident only)  
Benefit Period in Months
24    60
120     To Age 65
Optional Riders When Applicable
Own Occupation
Residual Disability  
Partial Disability
Future Insurability Option (Maximum)  
Cost of Living Benefit