Critical Illness Insurance Proposal

First Name:

Last Name:

Address:

 Apt # 

City:

Province:

Postal Code:

Home Number:

Work Number:

 Ext: 

Fax Number:

E-mail:

Member of which association?

Association (if not listed above):

Date of Birth:

Gender:

 male  female

Height:

 feet  inches

Weight:

 pounds

Do you currently have any health problems, (Back, Heart, Blood Pressure or Cholesterol)?

 No  Yes

Description of current health problems, including medications taken (if relevant)

Have you ever been treated for stress, back problems or any other illness that has or could have affected your ability to work.

 No  Yes

Description if yes

Have you ever smoked?

 yes  no

If yes, when was the last time?

--Select--< 1 yr1-2 yrs2-5 yrs5+yrs

Do you have a mortgage or other large debt?:

YesNo Amount of Loan:

Is it insured if you die:

Have any of your parents or siblings ever been diagnosed with a Life altering illness. e.g. Heart problems, Stroke, Cancer, Diabetes, etc.

If so please provide details. (illness, age @ onset, age if living, age @ death)

Do you engage in any higher risk activities?

Details if so.

Marital status:

Reason for buying insurance:

Our office hours are 8:30am to 4:30pm EST Monday through Friday. Please advise when during these hours it would be most convenient to contact you?

If you would like to make any additional comments, please enter them here.

Would you like to be added to our mailing list?

 Yes  No