Critical Illness Insurance

E-mail

Phone

E-mail address :

Daytime telephone number :  

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905     Ext. : 

Home telephone number :

Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905   

Name:

Sex

Male
Female

Date of birth

(dd / mm / yyyy)

If you belong to a group insurance plan, enter the name of your group

Have you ever had your insurance cancelled or refused?  

Yes No

Amount of coverage you want:  

$50,000 $100,000 $150,000
$200,000    Other, specify:  

Tell us about your health...

Overall health

Good   Poor

Have you smoked, or used any form of tobacco?

  In the past 5 years   Yes   No

  In the past year        Yes   No

If you quit smoking, when did you quit?

  Date:     Never:

Do you want a quote for your spouse/partner?

Yes   No

If yes, please provide:

Name

Sex

Male
Female

Date of birth

(dd / mm / yyyy)

If your spouse/partner belongs to a group insurance plan, enter the name of the group

Has your spouse/partner ever had their insurance cancelled or refused?  

Yes No

Amount of coverage requested

$50,000 $100,000 $150,000
$200,000   Other, specify  

Tell us about your spouse's/partner's health...

Overall health

Good   Poor

Have they smoked, or used any form of tobacco?

  In the past 5 years   Yes   No

  In the past year        Yes   No

If they quit smoking, when did they quit?

  Date:     Never: