Start QuickApp

QuickApp
EASY, FAST AND SECURE - START YOUR APPLICATION

Fill out the form below as completely as possible. After you have submitted your QuickApp, an experienced Life Insurance Advisor will contact you to confirm receipt and make sure you are applying for the best possible rate for your chosen term. The completed documents will then be delivered to you for signatures, after which time the application will then be submitted to the life insurance company. If you need assistance, please contact us toll-free 1.866.933.7888.

(!) Full Name

(!) Phone + area code

Alternate Phone

(!) Home Address (include postal code):

(!) Email Address:

(!) Date of Birth (Month, Day, Year):

(!) Place of birth (City, Country):

(!) What is your citizenship status?

(!) Have you ever used tobacco products?

If yes, indicate quantity:

(!) Do you drink alcohol?

If yes, how much and how often?

(!) Height:

(!) Weight:

(!) Has your weight changed by 10+ pounds in the last year?

If you answered yes, provide details:

(!) Name of your family doctor or usual medical clinic:

(!) Phone # and address of doctor or medical clinic:

(!) When did you last visit your doctor?

(!) What was the reason & result of your last visit? Was treatment or medication recommended or a followup visit arranged?

(!) Driver's License No. & Place of Issue:

(!) Name of your primary beneficiary:

(!) Relationship of the primary beneficary to you:

Name of secondary/contingent beneficiary (optional):

Relationship of secondary/contingent beneficiary to you:

If any beneficiary is a minor, please name a trustee:

Relationship of trustee to the beneficiary:

(!) Name of your employer. Include phone number and address:

(!) How long have you worked for your current employer?

(!) What is your occupation?

(!) Annual Income:

(!) Approximate Net Worth:

(!) If paying montly, choose day of month for withdrawal:

(!) Do you have other life insurance currently in force?

If you answered YES, please list policies you currently own & amount:

(!) Have you travelled outside Canada or USA in the last 12 months?

(!) Do you plan to travel outside Canada or USA in the next 12 moths?

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

(!) Enter Security Code

(!) Fields marked with (!) are required.

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

PRIVACY POLICY:
CanadaLifeQuote.com respects your privacy completely. We do not sell or distribute your personal and confidential information to anyone outside our company. We have never and will never send spam. And we will not include you on any mailing lists without your express consent. By leaving us with your contact information including your name, email address, and phone number, you agree that one of our experienced life insurance advisors can contact you and followup with you regarding our life insurance services only. Our advisors will never pressure you into a sale, nor will they continue to contact you if you are not interested. You don't want to send any private information over the internet? No problem, we can begin your application over the phone or in person. Contact us to arrange your appointment: 1.866.933.7888. Our goal is to provide you with timely life insurance products so you can save your hard earned money and precious time. Thanks again for using our QuickApp, from CanadaLifeQuote.com - the easiest way to get life insurance quotes online.

CanadaLifeQuote.com

The easiest way to get life insurance.