Professionalism & Quality Customer Service

Home

Get a Quote

About Us

Claims

Critical Illness Insurance

+	Customer Centre

Insurance

+	Financial Services

+	Resource Centre

Life Insurance

To get a no-obligation quote for Term Life Insurance, please complete the following form and submit it to our office. We will contact you within the next two business days. Please note that we can only provide insurance for residents of Ontario, Canada.

Your preferred means of communication for contact and follow-up :

E-mail
Phone

E-mail address :
Daytime telephone number :	Ext. :
Home telephone number :

Tell us about yourself...

Please Note : all fields must be completed for an accurate quote.

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 requested	$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:
Is this insurance intended to protect for a short term, or permanently (e.g., mortgage, dependant children, or final estate)?
Term Permanent
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:
Do you want a quote for any of your children under age 17?
Yes No
If yes, please provide:
Name
Sex	Male Female
Date of birth
	(dd / mm / yyyy)
If your child belongs to a group insurance plan, enter the name of the group

Has your child ever had their insurance cancelled or refused?
Yes No
Amount of coverage requested	$5,000 $10,000 $15,000 $20,000 Other, specify
Tell us about your child'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:

Comment

Your Privacy

You are authorizing that we collect, use or disclose your personal information contained on this information form as well as any additional information that we may obtain about you and other listed beneficiaries based on the information you have disclosed to us, (for example confirming your claims history or checking with motor vehicle agencies), for the purpose of providing you with this quote. By submitting this information form you also confirm that you have obtained the permission of all other potential beneficiaries listed on this information form for the collection, use and disclosure of their Personal Information for the purpose of providing you with this quote. Submission of this form does not constitute an application for insurance. Do you consent?

Yes No

Thank you for taking the time to fill out this form. Select the "Submit" button below and we will contact you within the next two business days. Our quote will include the coverages you selected. We will include the cost of popular optional coverages with our quotation.

* Coverage is subject to the insurer's underwriting policies.

** To learn more about the protection of your personal information, consult Privacy & Legal.