Your Full Name

Your Email

Your Phone Number (Incl. Area Code)

Home Address

Date of Birth (Month, Day, Year)

Gender
— Female Male

Place of Birth (City & Country)

What is your citizenship status?
— Canadian Landed Immigrant Student Visa Working Visa Other

Have you smoked in the past 12 months?
 No
 Yes

Height

ft, in cm

Weight

lbs kg

Family Physician (name, address and phone)

Date of Last VIsit to Doctor and Reason

Driver’s License No. & Province of Issue

List Your Primary Beneficiaries and their Relationship to You

List Your Secondary Beneficiaries and their Relationship to You

Your Current Occupation

Name of Your Employer, Their Address & Phone

How Long Have You Been With Your Current Employer?

— Less than 1 year 1 year 2 years 3 years 4 years 5 years Longer than 5 years

Your Annual Income
— up to $25,000 $25,001 – $35,000 $35,001 – $45,000 $45,001 – $55,000 $55,001 – $65,000 $65,001 – $85,000 $85,001 – $100,000 > $100,00

Your Net Worth
— up to $25,000 $25,001 – $50,000 $50,001 – $75,000 $75,001 – $100,000 $100,001 – $150,000 $150,001 – $250,000 $250,001 – $500,000 $500,001 – $1,000,000 > $1,000,000

If you have other life insurance in force, please list details below

In the past 12 months, have you travelled outside Canada or the USA?
 No
 Yes

In the NEXT 12 months, do you plan to travel outside Canada or the USA?
 No
 Yes

If you answered YES to the travel questions, please indicate locations of travel, length of visit, and purpose of each visit

To Verify Your Application, Enter the Security Code:

A short medical questionnaire by telephone will follow most life insurance applications.