Life Insurance Enrolment Online

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Summary of Selected Plan:

Carrier: .
Plan: .
Face Amount: $ (the amount of coverage)
Type of Plan: .
Premium: $/month.
Health Class:

SSL Encryption * not required

Part A - Personal Data
First name:
Last name:
Middle name: * Maiden name
(if applicable):
*
Date of Birth:    
Gender:
Smoker:
Height:
Weight:
Street Address:
City:
Postal Code:
Province:
Length of time you have spent at your current residence:
Telephone:
Email:
I was born in: Resident Status:
Beneficiary:
Relationship to Beneficiary:
Part B - Plan & Health Data
Occupation:
Typical Duties:
Name of Employer:
Address of Employer:
Income: $ /year
Time with Employer:
Please answer the following health questions:
1) Has any insurer ever declined to issue, reinstate or renew, or has any insurer ever rated, modified, postponed or cancelled any life or health insurance on your life? No     Yes
2) Will this policy change or replace any existing life insurance or annuity policy with this or any insurer? No     Yes
3) In the past year have you, or in the next 2 years do you plan to, travel outside of North America? No     Yes
4) Have you ever been convicted of any criminal offence? No     Yes
5) Have you had, been diagnosed with, been prescribed, or taken medication for the following: heart attack, stroke, diabetes (requiring insulin) or cancer? No     Yes

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