Insurance applications are pretty comprehensive because all of the underwriting is done beforehand. However they do not need to take a lot of time. Much of the information that we will need can be completed in advance by using this form.

What to expect:
1) We will take the information you provide on this form and prepare the documents in advance of your meeting with your advisor.
2) On the day of your appointment, your advisor will go through a set of health questions that range from family history, to lifestyle activities, to your own personal medical background.
3) Once that is completed, you will have the opportunity to sign the application at which point we will submit the documents to the insurance carrier for underwriting.
4) Insurance approvals can can be instantaneous in some cases. Underlying medical conditions or requests for bloodwork can delay the underwriting process as the insurance carrier may need to review doctor reports and test results.
5) If you are submitting an application for multiple person, please use a separate email for each applicant.

Is the insurance for a child? *

Adult Application

Child Application

PERSONAL INFORMATION

First Name

Last Name

Phone *

Email *

SIN *

Country of Birth *

Date of birth *

Address *

Postal code *

How long at this address? *

EMPLOYMENT AND NET WORTH

Employer *

Employment Status *

Employer Address *

Income per year *

Years / Months with Current Employer *

Employment - Industry *

Job Title *

Previous Employer (If less than 5 years with current employer)

Years / Months with Previous Employer

Mortgage Bank / Landlord *

Mortgage Balance / Rent Payment ($0.00 If Not Applicable) *

Have you ever declared bankruptcy? *

Yes

Assets *

Liabilities *

LIFESTYLE QUESTIONS

Smoking Status *

Height and Weight *

Weight gain/loss in the last 12 months?

How often do you drink? *

Do you participate in hazardous activities? *

Yes

Family Doctor / Clinic *

Family Doctor Address *

Family Doctor - Date of Last Visit *

Family Doctor - Purpose of Last Visit *

BENEFICIARIES AND INSURANCE HISTORY

Marital Status *

Beneficiaries Names, Relationship, Birthdates (mm/dd/yyyy), Percentage(s) *

Backup Beneficiaries

Have you ever had an application for insurance Declined, Postponed, or Rated? *

Yes

Additional Notes

Primary ID / Drivers Licence

Secondary ID / Other Government Issue ID

Void Cheque