My Life Insurance Application Details

Life Insurance Application Details
Please fill the details as accurate as possible for better assistance
First Name*
Last Name*
Last Name at Birth (if Different from Present Name)*
Type NA if Last Name was not different at Birth
Date of Birth*

MonthDay Year
Date
Email Address*
example@example.com
Phone Number*
Address*

Street Address
Street Address Line 2
City State / Province
Postal / Zip Code

Birth place and Immigration Status
Were you born in Canada?*

YesNo
Place of Birth*
In Canada Since? (Month and year)*
Residency Status*

Taxation and Financial Info Details
Are you a US citizen or a US resident for tax purposes?*

YesNo
Are you a tax Resident in a jurisdiction other than Canada or USA?*

YesNo

Employment
Your Occupation?*
Since When*

MonthDay Year
Date
Annual Income before taxes?*
Your Net Worth*
Assets - Liabilities
Employer Name*
Type of Business*
Employer Full Address*

Family Doctor
Doctor/Physician Name*
Doctor's Phone Number*
Full Address*

Driver's License Related
Driver's License Number*
Driver's License Expiration Date*

MonthDay Year
Date
Within the last 5 years, has your driver's license been suspended or revoked (excluding due to unpaid fines)?*

YesNo
Within the last 3 years have you had 4 or more driving violations (excluding parking tickets)?*

YesNoOther

Current In-force Insurance Details
Do you have any other pending insurance applications?*

YesNo
Have you ever been declined for insurance?*

YesNo
Do you have an in-force insurance on your life, excluding group insurance or creditor insurance?*

YesNo

Beneficiaries
Beneficiary First Name*
Beneficiary Last Name*
Beneficiary Date of Birth*

MonthDay Year
Date
Relationship with Beneficiary?*
Cont. Beneficiary First Name*
Cont. Beneficiary Last Name*
Cont. Beneficiary Date of Birth*

MonthDay Year
Date
Cont. Relationship with Beneficiary?*

Alcohol Consumption related
On an average do you consume more than 12 alcoholic beverages per week?*

YesNo
Have you been treated for drug or alcohol use, been a member of a support group or have ever been advised to reduce your consumption or to received treatment for it?*

YesNo

Family Medical History
Has any member of your family (father, mother, brother, sister) suffered from one of the following conditions before the age of 65?
You are not required to disclose a family history of hypertension, high cholesterol, or depression.
1. Cancer*
2. Multiple sclerosis
3. Amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
4. Polycystic kidney disease**
5. Death from an unknown cause
6. Cardiovascular disease (e.g.: CVD, myocardial infarction)
7. Parkinson’s disease
8. Neurological disease** (excluding epilepsy)
9. Hemophilia**
10. Diabetes
11. Alzheimer’s disease
12. Huntington’s chorea**
13. Any other hereditary disorder** (specify):
14. I don’t know since I was adopted, or I have no contact with my family
15. None of the Above
Select the Option

Personal Medical History
Do you currently take any medication prescribed by a physician? (Reason, Dosage)*
Have you sought medical attention or received treatment for or been told you have symptoms of any of the following diseases or disorders?

Cerebral vascular accident/stroke (CVA)/Transient ischemic attack (TIA)Angina /Heart attack (with or without bypass surgery/angioplasty)Cancer/Malignant tumor (any site)Major depression (in the last five years) or Bipolar disorder (any duration)DiabetesHepatitis B or C (other than carrier)Crohn’s disease /Ulcerative colitis diagnosed in the last 8 yearsChronic obstructive pulmonary disease (COPD)/ EmphysemaRheumatoid arthritis polyarthritis/SpondylarthritisNone of the Above
Please provide details for each disease or disorder indicated.

Disease or disorder Date of diagnosis Have you been hospitalized or did you
undergo a surgery? If yes, specify the date
1
2
3
4
Have you consulted, within the past 5 years, a Physician, Chiropractor or other practitioner, undergone a medical examination or been treated in a hospital clinic or other facility?*

YesNo
Are you currently under medical investigation awaiting results or do you have any signs or symptoms for which you have not yet consulted a doctor or for advice to undergo a diagnostic test that has not been yet performed?*

YesNo
In the last 3 years have you undergone any diagnostic tests including ultrasound, ECG, CT scan, MRI, biopsy, Colonoscopy, etc. ?*

YesNo
In the last 5 years, have you consulted or been treated for muscle or bone disorders (arthritis, tendinitis, back pain, fracture, neck pain, joint pain)?*

YesNo
In the last 5 years have you been consulted or been treated for any mental illness (e.g. depression, anxiety, suicide attempt, stress, insomnia, personality disorder)?*

YesNo
Have you tested positive for AIDS screening test or for Hepatitis B or C?*

YesNo
In the past year have you practised aviation, scuba diving, parachuting, risky winter sports, paragliding mountaineering, climbing, skydiving, motorcycle racing, or a plan to do so in the next year?*

YesNo
In the last 10 years have you been incarcerated or convicted for any criminal offence?*

YesNo
Do you have any physical abnormalities ?*

YesNoOther
Do you suffer from or have you ever been diagnosed with a disorder or disease of the nervous system or a neurological condition
1. Alzheimer's disease,
2. Down syndrome,
3. Parkinson's disease,
4. Autism,
5. Cerebral palsy,
6. Mental impairment,
7. Developmental disorder,
8. Multiple sclerosis,
9. Amyotrophic lateral sclerosis, etc)
10. None of the Above
Select the Option

Height and Weight Related
Height (Please mention in feet or cm)*
Weight (Please mention in Kg or lbs)*
In the past year have you lost more than 5 kg's? (excluding weight loss from childbirth)*

YesNo
In the past year have you lost more than 5 kg's? (excluding weight loss from childbirth)*

YesNo

Travel Related
In the next 2 years do you plan to travel or reside outside of Canada or the United States for more than 9 weeks?*

YesNo
In the last four weeks have you travelled outside of Canada or have you transited through an airport?*

YesNo

COVID-19 Related Questionnaire
Are you experiencing symptoms of fever, cough or difficulty breathing ?*

YesNo
In the last four weeks have you or someone close to you been in contact with a confirmed or suspected case of COVID-19 corona virus infection?*

YesNo
In the last 12 months have you been hospitalized for the COVID-19 corona virus disease?*

YesNo

Review and Submit
By Clicking I agree, I am agreeing to Privacy policy whose document has been handed over to me in person by Advisor.*

I Agree
Any Details you would like to add, which has not been mentioned in the form ? or Any Comments about any question ?
Should be Empty:

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	Disease or disorder	Date of diagnosis	Have you been hospitalized or did you undergo a surgery?	If yes, specify the date
1
2
3
4