Term Life Insurance

Term Life Insurance Quote
(Please submit one form per applicant.)

Yes, I want the lowest priced life insurance with a good company and as quickly as possible. Please let me know the premium.

Has the Proposed Life Insured had, or have ever been told he/she, had or consulted a physician for, or received treatment for any of the following:
Yes
No
A) Disorder of the heart or blood vessels including elevated or high blood pressure?
B) Chest pain, angina, heart attack, or stroke?
C) Cancer or tumour?
D) Acquired Immune Deficiency Syndrome (AIDS) AIDS Related Complex (ARCS) or any other immunological disorder?
E) Within the past two years, has the proposed Life Insured had any symptoms of, treatment for, any medical conditions that resulted in hospitalization for more than five days?
F) Has the Proposed Life Insured ever applied for life insurance which has been declined, rated or modified in any way?
G) Within the past 90 days has the Proposed Life Insured been unable to perform the normal duties of his/her occupation for fifteen or more working days because of health reasons?
H) Does the present life insured intend to replace or convert a policy?
(N.B. Replacements and conversions cannot be handled with this quick issue process.)
First Name  
Last Name  
Gender Male Female  
Date of Birth (d/m/y)  
Smoked in last 12 months? Yes No  
Province  
City  
Home Telephone - -  
Work Telephone - - Ext:  
Email  
Contact Me  
Policy Amount  
Term  
Pay Monthly Annually  
     
   


1405 Bishop Street, Suite 216, Montreal, Canada, H3G2E4
Tel: (514) 842-9001 - National Toll Free: (877) 842-3863


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