Name?

E-mail address:  

Telephone Number:  

Province of Residence  

Date of Birth:   Day Month Year

Ever use tobacco or marijuana? yes no

If yes to above, when last quit?

Gender: MaleFemale

Amount of Insurance:

Please indicate if you want :

• Single Life:
• Joint 1st to die coverage:
• Joint 2nd to die coverage:

For joint 1st to die or joint 2nd to die coveage there will be two or more persons involved. Please enter their names, gender, date of birth and smoking habits in the text box below. The death benefit will be the same as the primary person requesting this information.

Type of Insurance [You may choose up to three]:

• 10 Year Term
• 15 Year Term
• 20 Year Term
• Level Term to 65
• Level Term to 71
• Level Term to 75
• Level Term to 100
• Reducing Mortgage Term
• Whole Life, pay for life
• Whole Life, pay to age 65
• whole life, pay for 20 years
• Whole Life, quick pay
• Critical Illness, living benefit