Powered By
Application
Fast
Simple
Easy
Form
Back To Website
Phone
This field is for validation purposes and should be left unchanged.
I'm looking life insurance for a
(Required)
Boy
Girl
DOB (MM/YYYY)
(Required)
MM slash DD slash YYYY
My postal code is
(Required)
I'm a
(Required)
Canadian citizen/resident
Non-resident
Coverage Amount (adjust between $50,000 and $250,000)
(Required)
Please enter a number from
50000
to
250000
.
Payment Period
(Required)
Life Pay
20 Pay
View growth in
(Required)
Coverage Amount
Cash Value
Select Quote (Provider)
(Required)
Desjardins
Empire Life
Equitable
BMO Insurance
Manulife
Canada Life (quotes available on request)
Address
(Required)
Book your call - Select a day
(Required)
1 Thu
2 Fri
3 Sat
4 Sun
5 Mon
Choose your timezone
(Required)
Select timezone
America/Toronto - GMT (-05:00)
America/Vancouver - GMT (-08:00)
Select a time slot
(Required)
03:30 am
04:00 am
04:30 am
05:00 am
05:30 am
06:00 am
06:30 am
08:00 pm
10:00 pm
10:30 pm
11:00 pm
Email
(Required)
Phone
Step
1
of
4
- Basic Info
25%
What is your gender?
(Required)
Male
Female
When were you born?
(Required)
MM slash DD slash YYYY
Tell us about your smoking status
(Required)
Non-smoker
Smoker
What is your postal code?
(Required)
Do you currently reside in Canada?
(Required)
Yes
No
Do you know what monthly premium works best for your whole life policy?
(Required)
Yes
No
Monthly Premium
Payment Period
Life Pay
Pay for 20 years
What is your height?
ft-in
Cms
ft
in
Cms
What is your weight?
Kgs
Lbs
Kgs
Lbs
Have you used any tobacco products in the last 5 years?
Cigarettes
Cigars
Pipes
Chewing tobacco
Nicotine patch/gum
Vaping products
Not used
Treated for or taken medication for high blood pressure?
Yes
No
If Yes, when were you last treated for high blood pressure?
Treated for or taken medication for high cholesterol?
Yes
No
If Yes, when were you last treated for high cholesterol?
Driving History - DUI, reckless, license issues, accidents
Yes
No
Occupation
Employment Status
Select Status
Salaried
Self-employed
Retired
Unemployed
Are you incorporated?
Yes
No
How many employees does your company have?
Less than 2
2‑4
5‑9
10+
What is your current occupation?
What is your annual income?
Choose your preferred call date
MM slash DD slash YYYY
Choose your timezone
Asia/Karachi GMT +05:00
Choose available time slot
12:00 am
02:00 am
03:30 am
08:00 pm
11:00 pm
Email
Phone
Step
1
of
3
- Basic Info
33%
Gender
Male
Female
Do you smoke?
Yes
No
Date of Birth
MM slash DD slash YYYY
Are you Canadian citizen/resident?
Yes
No
Postal Code
What is your current occupation?
How long have you been employed in your current occupation?
What is your annual individual income (pre-tax)?
How many hours per week do you work?
Do you currently have disability coverage?
Yes
No
Please enter monthly benefit amount per your existing disability coverage. Estimate will be fine too.
Are you looking to replace the existing disability coverage?
Yes
No
How much monthly payments would you like? (min)
How much monthly payments would you like? (max)
When would you want your payments to begin?
30 Days
60 Days
90 Days
120 Days
Address
Postal Code
City
Are you aware of any signs, symptoms, or any abnormal diagnostic test for which:
You have not yet consulted a physician?
Yes
No
You are currently being investigated?
Yes
No
You have a pending consultation with a medical specialist?
Yes
No
You have consulted with a medical specialist without having recieved a diagnosis?
Yes
No
You are currently awaiting surgery (other than day surgery/outpatient surgery)?
Yes
No
Within the last twelve (12) months, with regards to depression or any mental health diagnosis:
Have you been hospitalized?
Yes
No
Has your medication been changed (addition or replacement of a medication, increase or decrease of dosage)?
Yes
No
Have you ceased your medication without being advised by your doctor to do so?
Yes
No
Do you have diabetes?
Yes
No
Is this type 1 or type 2 diabetes?
Yes
No
Within last 12 months, has your medication changes as advised by a physician (addition or replacement of a medication, increase or decrease of dosage)?
Yes
No
Book your call
Hours
:
Minutes
Email
(Required)
Phone
Step
1
of
4
- Basic Info
25%
What is prompting you to explore health insurance?
(Required)
I don't currently have private health coverage
I have private health coverage but want better benefits or compare options
I'm self-employed, an independent contractor or a business owner
I'm losing my coverage or changing jobs
I'm retired or planning to retire soon
I'm new to Canada and need health coverage
I'm just exploring my options
Gender
(Required)
Male
Female
Date of birth
(Required)
MM slash DD slash YYYY
What is your employment status?
(Required)
Select Status
Employed
Self-employed
Not currently working
Retired
Student
Are you incorporated?
(Required)
Yes
No
How many employees does your company have?
1
2-4
5-9
10-19
20-49
50+
What is your occupation?
(Required)
Select Occupation
Accountant / Bookkeeper
Administrative / Office
Construction / Trades
Education
Healthcare
Hospitality / Service
IT / Tech
Management / Executive
Sales / Marketing
Transportation
Other
What is your annual income?
(Required)
Please enter a number greater than or equal to
1
.
dollars
Your province of residence
(Required)
Select Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
Additional applicants
0
1
2
3
4
Relationship with primary applicant
Spouse
Partner by common-law
Dependent child
Applicant 2 gender
Man
Woman
Applicant 2 date of birth
MM slash DD slash YYYY
Relationship with primary applicant
Spouse
Partner by common-law
Dependent child
Applicant 3 gender
Man
Woman
Applicant 3 date of birth
MM slash DD slash YYYY
Relationship with primary applicant
Spouse
Partner by common-law
Dependent child
Applicant 4 gender
Man
Woman
Applicant 4 date of birth
MM slash DD slash YYYY
Relationship with primary applicant
Spouse
Partner by common-law
Dependent child
Applicant 5 gender
Man
Woman
Applicant 5 date of birth
MM slash DD slash YYYY
Are all the applicants covered by a provincial government health care plan?
(Required)
Yes
No
Are you replacing any existing health and dental insurance?
(Required)
Yes, replacing employer coverage
Yes, replacing personal insurance
No, this is new coverage
Have your group benefits ended or will they end within 90 days?
(Required)
Yes, within the last 90 days
Yes, in the next few days
No, but more than 90 days ago
Do you or a covered family member need coverage for pre-existing health conditions or medications?
(Required)
Yes — we would like coverage for existing health condition
No — we don’t need coverage for existing health condition
Which coverage combination do you need?
(Required)
Health & Dental - Full Coverage
No Dental Plans
No Drugs Plans
When do you plan to secure your health and dental insurance coverage?
(Required)
Immediately, as soon as possible
Within the next 3 months
In the next 6 months
I am still exploring
Most people also add extra protection—would you like to see quotes for these too?
Life Insurance
Disability Insurance
Critical Illness Insurance
Travel Insurance
Select quote preference
(Required)
Lowest monthly premium
Best value
Most coverage
Not sure
Address
(Required)
Choose your timezone
(Required)
Select timezone
America/Vancouver - GMT (-08:00)
America/Edmonton - GMT (-07:00)
America/Winnipeg - GMT (-06:00)
America/Toronto - GMT (-05:00)
America/Halifax - GMT (-04:00)
Asia/Karachi - GMT (+05:00)
Choose a time slot to speak to our advisor
(Required)
01:00 am
03:30 am
04:00 am
04:30 am
05:00 am
05:30 am
06:00 am
06:30 am
08:00 pm
10:00 pm
10:30 pm
11:00 pm
Email
(Required)
Phone Number
Step
1
of
4
- Basic Info
25%
What is your gender?
(Required)
Male
Female
When were you born?
(Required)
MM slash DD slash YYYY
Your premium depends on your age and insurance companies have a unique way of calculating it based on your nearest birthday.
Tell us about your smoking status
(Required)
Non-smoker
Smoker
You’re considered a smoker if in the past 12 months you have used any form of tobacco products (cigarettes, cigarillos, pipes, chewing tobacco, e-cigarettes, hookah, nicotine patch/gum), smoked more than one large cigar per month and/or vaped.
What is your postal code?
(Required)
Do you currently reside in Canada?
(Required)
Yes
No
Coverage is available to all Canadian residents, including new immigrants!
When would you prefer your coverage to start?
(Required)
Immediately, as soon as possible
Within the next 1-3 months
I am researching my options (but rates may rise)
Do you know the critical illness insurance amount you need?
(Required)
Yes
No
I need insurance of
(Required)
Our insurance experts will recommend the right critical illness policy based on your protection needs. We’ve helped over 650,000 Canadians secure their financial future against unexpected health challenges.
What is your employment status?
(Required)
Select Status
Employed
Self-employed
Unemployed
Student
Retired
Are you incorporated?
Yes
No
How many employees does your company have?
(Required)
1-2
5-10
12-15
20-25
30-40
What is your current occupation?
(Required)
Select occupation
Accountant
Administrative assistant
Construction worker
Driver
Engineer
Healthcare worker
IT / Software
Manager
Sales
Teacher
Other
What is your annual income?
(Required)
Enter annual income in dollars.
Coverage
(Required)
Term
(Required)
10 years
20 years
Age 65
Age 75
Age 100
Payment frequency
(Required)
Pay Monthly
Pay Yearly
Filter
All
Basic
Enhanced
Add Return of Premium
Add Return of Premium
Available Quotes (Select)
(Required)
Manulife
Sun Life
The Canada Life Assurance Company
iA Financial Group (Industrial Alliance)
Equitable Life of Canada
Assumption Life
Canada Protection Plan (CPP)
Desjardins insurance
Do you have a spouse or a significant other?
(Required)
Yes
No
Address
(Required)
Are you aware of any signs, symptoms, or any abnormal diagnostic test for which:
(Required)
Yes
No
You have not yet consulted a physician?
You are currently being investigated?
You have a pending consultation with a medical specialist?
You have consulted with a medical specialist without having received a diagnosis?
You are currently awaiting surgery (other than day surgery/outpatient surgery)?
Within the last twelve (12) months, with regards to depression or any mental health diagnosis:
(Required)
Yes
No
Have you been hospitalized?
Has your medication been changed (addition or replacement of a medication, increase or decrease of dosage)?
Have you ceased your medication without being advised by your doctor to do so?
Do you have diabetes?
(Required)
Yes
No
Is this type 1 or type 2 diabetes?
(Required)
Type 1
Type 2
Within last 12 months, has your medication changed as advised by a physician (addition or replacement of a medication, increase or decrease of dosage)?
(Required)
Yes
No
Email
(Required)
Phone
Name
(Required)
First
Last
Email
Gender
(Required)
Select Your Gender
Male
Female
Non-binary
Agender
My gender is not listed
Prefer not to answer
Occupation
(Required)
Select Occupation
Accountant
Architect
Construction Worker
Designer
Doctor
Engineer
IT Professional
Manager
Nurse
Sales
Teacher
Other: Please specify
Other (Occupation)
Client Preferred Language
(Required)
Select Your Language
English
French
Mandarin
Cantonese
Punjabi
Spanish
Arabic
Tagalog (Filipino)
Hindi
Urdu
Persian (Farsi)
Portuguese
Russian
Korean
Vietnamese
Italian
German
Polish
Gujarati
Bengali
Tamil
Phone
Mailing Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Property Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Applicant Status
Select Status
Owner
Landlord
Tenant
Property Type
Select
Townhouse
Condo
Detached House
Semi-Detached
Duplex
Tenant Unit
Other (please specify)
Other (please specify)
Ideal Effective Date
(Required)
MM slash DD slash YYYY
Purchase Completion Date
(Required)
MM slash DD slash YYYY
(New purchases only)
Step
1
of
3
- Basic Info
33%
What is your company's name?
(Required)
Which industry does your company operate in?
(Required)
Do you currently have an existing group benefits for your employees?
(Required)
Yes
No
Current provider / insurer
(Required)
Renewal date
(Required)
MM slash DD slash YYYY
When would you like your coverage to begin?
(Required)
Immediately, as soon as possible
Within the next 1-3 months
I am still exploring
What is prompting you to explore new benefits?
(Required)
Attract and retain top talent
Team wants better benefits
Staying competitive in the industry
Just exploring options
Which province is your company located in?
(Required)
Select Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
Northwest Territories
Nunavut
Yukon
We compare quotes from Canada's leading group insurance providers. Prefer a specific one? Let us know, we'll include it in the comparison.
Manulife
Sun Life
The Canada Life Assurance Company
iA Financial Group (Industrial Alliance)
Equitable Life of Canada
Assumption Life
Canada Protection Plan
Desjardins insurance
Compare the best providers from above list
Compare the best providers from above list
Which add on benefits are important to you?
Health Spending Account
Extended Dental Coverage
Critical Illness Insurance
Virtual Healthcare
Disability Insurance
Employee Assistance Program
How many employees need coverage?
(Required)
Please enter a number greater than or equal to
1
.
Single:
(Required)
Please enter a number greater than or equal to
0
.
Couple:
(Required)
Please enter a number greater than or equal to
0
.
Family:
(Required)
Please enter a number greater than or equal to
0
.
Select a plan
(Required)
Silver Plan
Gold Plan
Platinum Plan
Choose a time slot to speak to our advisor (Date)
(Required)
1 Thu
2 Fri
3 Sat
4 Sun
5 Mon
Choose your timezone
(Required)
Select timezone
Asia/Karachi - GMT (+05:00)
America/Toronto - GMT (-05:00)
America/Vancouver - GMT (-08:00)
Choose a time slot
(Required)
01:00 am
03:30 am
04:00 am
04:30 am
05:00 am
05:30 am
06:00 am
06:30 am
08:00 pm
10:00 pm
10:30 pm
11:00 pm
Email
(Required)
Phone Number
Step
1
of
4
25%
Travel Options
Short term Visitors to Canada
Super Visa
Travelling Candians
International Students
Buying policy for self?
(Required)
Yes, i am the primary traveller
No, buying for someone else
For whom are you buying this policy?
Insurance Type
(Required)
Visitors to Canada
Super Visa
International Students
Travelling Canadians
Snowbirds
Foreign Workers
Province
Alberta
British Columbia
Manitoba
Ontario
Travelling to country
(Required)
Germany
Dubai
France
Paris
Coverage Start Date
MM slash DD slash YYYY
Coverage End Date
MM slash DD slash YYYY
Primary Traveller's Name
(Required)
First Name
Last Name
Primary Traveller's Date of Birth
MM slash DD slash YYYY
Are there additional traveller
(Required)
Yes
No
Coverage Amount
(Required)
$500
$1000
$1500
$2000
Coverage refer to the amount of coverage that will be payable upon claim
Deductible
$500
$1000
$1500
$2000
Amount of money you pay towards expenses should you have to file a claim with your travel insurance provider
Your email address
(Required)
Your mobile number
Arrival Date in Canada
MM slash DD slash YYYY
Visiting Province
Alberta
British Columbia
Manitoba
Ontario
Country of origin for traveller
Germany
Dubai
France
Paris
Coverage Start Date
MM slash DD slash YYYY
Coverage End Date
MM slash DD slash YYYY
Who is purchasing this plan?
(Required)
Yes, i am the primary traveller
No, buying for someone else
Purcahser's Name
(Required)
First Name
Last Name
Purchaser's Occupation
Accountant
Developer
Teacher
Annual Income
(Required)
$500
$1000
$1500
$2000
For whom are you buying this policy?
Your mobile number
(Required)
Choose the right travel insurance
(Required)
Single Trip Travel Insurance
Multi-Trip Travel Insurance
Your home province
Germany
Dubai
France
Paris
When do you want the coverage to start?
MM slash DD slash YYYY
When do you want the coverage to end?
MM slash DD slash YYYY
Maximum travel days per trip
1-10 days
10-15 days
15-20 days
20-25 days
Trip destination
Germany
France
Paris
Maldives
Any stop over in the US?
1 day
2 days
3 days
4 days
Any of the travellers has a pre-existing medical conditions?
Yes
No
Have any travellers smoked within past two years?
Yes
No
Do all travellers have valid Canadian Government health insurance?
Yes
No
Primary Traveller's Name
(Required)
First Name
Last Name
Primary Traveller's Date of Birth
MM slash DD slash YYYY
Occupation
Accountant
Developer
Teacher
Annual Income
$500
$1000
$1500
$2000
Any stable pre-existing medical conditions?
Yes
No
Are you travelling as a family?
Yes
No
Complete online offering
Flexible plan for multi-stop travel
Stress-free travel with monthly premium
Long-term plans with companion discounts
Known for customizable deductibles
Easy access to diverse plans
Insurance that supports pre-existing conditions.
Address Line 1
Address Line 2
City
Postal Code
Phone Number
Province
Alberta
British Columbia
Manitoba
Ontario
Beneficiary Full name
First
Last
Relationship with the applicant
Spouse
Son
Daughter
Mother
Father
Payment Options
One-time Payment
Monthly Payment
Have you been advised against travel by a physician?
Yes
No
Do you have a surgically untreated aneurysm?
Yes
No
Have you ever been diagnosed with or received treatment for cancer, heart failure, organ transplant
Yes
No
Do you currently reside in a nursing home, assisted living home, convalescent home, hospice or rehabilitation center?
Yes
No
Do you require assistance with normal daily activities?
Yes
No
Have you taken oral steroids, or used home oxygen to treat lung condition in the 12 months before you start date?
Yes
No
Please check each condition you have been diagnosed with or treated for in the 12 months before you start:
Coronary Artery Disease
Yes
No
Valvular Heart Disease
Yes
No
Heart arrhythmia
Yes
No
Diabetes requiring insulin
Yes
No
Blood clots
Yes
No
Gastro-intestinal Bleed
Yes
No
Aneurysm
Yes
No
Were you admitted to the hospital for this condition in the 12 months before your start date?
Yes
No
Phone
Name
Step
1
of
6
- Basic Info
16%
Gender
Male
Female
Smoking Status
Smoker
Non-smoker
Date of Birth
MM slash DD slash YYYY
Postal Code
Who needs coverage?
Yourself
Yourself and partner
Term
5 Years
10 Years
15 Years
20 Years
Full Name
(Required)
First
Last
Home Address
Street Address
City
State / Province / Region
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
CĂ´te d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
RĂ©union
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
TĂĽrkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Ă…land Islands
Country
Province of Residence
(Required)
Select Residence
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Citizenship / Residency Status
(Required)
Canadian citizen
Permanent resident
Work permit / temporary resident
Other / not sure
Country of Citizenship
How many years have you lived in Canada?
Please enter a number from
0
to
100
.
Preferred Contact Method
(Required)
Phone call
Text message
Email
Why are you looking for life insurance?
Secure your family's future
Mortgage and debt protection
Replace an existing policy
Build wealth for future
Access cash for retirement
Cover end-of-life expenses
When do you want coverage to start?
Immediately
Within the next 1-3 months
I am researching my options (but rates may rise)
Do you know how much coverage you need?
Yes
No
Desired coverage amount
Do you have a mortgage or other debts?
Yes
No
Approximate mortgage balance
Enter the approx. outstanding balance on your mortgage or home equity loans.
Mortgage payoff timeline (years)
Enter the maximum term of the mortgage or home equity loan.
Other debts (total)
Include balance outstanding on any other debt e.g. your credit cards, car loan, business loan, student loan, etc
Other debt payoff timeline (years)
How many children do you have?
Include number of dependent children for whom you will provide tuition support. Also include nay children you plan to have in the next 1-2 years.
What is their age (in years)
Helps adjust education needs for inflations.
What is the average cost you will pay for college education?
a year per child
How much is your current annual income (after tax)
a year
What would you like to provide for your beneficiaries?
of income
For
years
What amount of coverage do you want for funeral expenses?
Funeral expenses vary between $1,500 - $20,000
What amount of additional coverage do you want?
What amount of life insurance coverage do you already have?
How much have you saved for retirement (e.g., in a Registered Retirement Savings Plan - RRSP)?
How much do you currently have in non-retirement savings and investments?
What is your height?
ft-in
Cms
ft
in
Cms
What is your weight?
Lbs
Kgs
Lbs
Kgs
Have you used any tobacco products in the last 5 years?
Cigarettes
Cigars
Pipes
Chewing tobacco
Nicotine patch/gum
Vaping products
Not used
Have you ever been treated for or taken medication for high blood pressure?
Yes
No
Have you ever been treated for or taken medication for high cholesterol?
Yes
No
Have you been convicted of drunk driving (DUI/DWI) or reckless driving , or has your license been revoked or suspended, or have you been involved in any accidents?
Yes
No
Have you ever been diagnosed with diabetes (Type 1 or Type 2)?
Yes
No
Have you ever been diagnosed with diabetes (Type 1 or Type 2)? - Details
Have you ever had heart disease, heart attack, stroke, or been advised to have cardiac testing/procedures?
Yes
No
Have you ever had heart disease, heart attack, stroke, or been advised to have cardiac testing/procedures? - Details
Have you ever been diagnosed with cancer, tumor, or leukemia?
Yes
No
Have you ever been diagnosed with cancer, tumor, or leukemia? - Details
In the past 5 years, have you been treated for depression, anxiety, or any mental health condition?
Yes
No
In the past 5 years, have you been treated for depression, anxiety, or any mental health condition? - Details
Have you ever been diagnosed with sleep apnea?
Yes
No
Have you ever been diagnosed with sleep apnea? - Details
In the past 5 years, have you been hospitalized, had surgery, or been advised to have surgery?
Yes
No
In the past 5 years, have you been hospitalized, had surgery, or been advised to have surgery? - Details
Do you currently take any prescription medication (other than birth control)?
Yes
No
Do you currently take any prescription medication (other than birth control)? - Details
Do you participate in any hazardous activities (e.g., scuba, skydiving, aviation, racing, mountaineering)?
Yes
No
Hazardous Activities - Details
Do you plan to travel or live outside Canada/USA for more than 30 days in the next 12 months?
Yes
No
Travel Plans - Details
Alcohol consumption (average)
None
1-3 drinks/week
4-7 drinks/week
8-14 drinks/week
15+ drinks/week
Prefer not to say
Have you used recreational drugs in the past 5 years (including cannabis where applicable)?
Yes
No
Recreational Drug Use - Details
Has any immediate family member (parent/sibling) died before age 60?
Yes
No
Family History - Early Death Details
Family history (check all that apply)
Heart disease / stroke
Cancer
Diabetes
None of the above
Employment status
Select Status
Salaried
Self-employed
Retired
Unemployed / In between jobs
Student
Are you incorporated?
Yes
No
How many employees does your company have?
less then 2
2-4
5-7
10-19
20-49
50-100
100+
What is your current occupation?
Select Occupation
Accountant
Sale manager
Web developer
What is your annual income?
dollars
Preferred insurer / options
Empire Life
Illness advance
Family discount
Schedule a Call
Pick a date and time that works best. We'll confirm by your preferred contact method.
Choose a call date
(Required)
MM slash DD slash YYYY
Choose a time
(Required)
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
Your time zone
(Required)
Select Timezone
Pacific Time (PT) — Vancouver
Mountain Time (MT) — Calgary
Central Time (CT) — Winnipeg
Eastern Time (ET) — Toronto
Atlantic Time (AT)
Newfoundland Time (NT)
Beneficiaries
Primary Beneficiary Full Name
(Required)
Primary Beneficiary Relationship
(Required)
Select Beneficiary Relationship
Spouse/Partner
Child
Parent
Sibling
Other
Primary Beneficiary Percentage (%)
(Required)
Please enter a number from
1
to
100
.
Would you like to add a second beneficiary?
Yes
No
Second Beneficiary Full Name
Second Beneficiary Relationship
(Required)
Spouse/Partner
Child
Parent
Sibling
Other
Second Beneficiary Percentage (%)
(Required)
Please enter a number from
1
to
100
.
Email
(Required)
Phone Number
Name
(Required)
First
Last
Client Preferred Language
(Required)
Select Your Language
English
French
Mandarin
Cantonese
Punjabi
Spanish
Arabic
Tagalog (Filipino)
Hindi
Urdu
Persian (Farsi)
Portuguese
Russian
Korean
Vietnamese
Italian
German
Polish
Gujarati
Bengali
Tamil
Phone
Email
Registered Name
Business Name
Property Address
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Applicant Status
Select Status
Owner
Landlord
Tenant
Business Status
Select
Sole Proprietorship
Partnership
Limited Company
Other
Other (please specify)
Ideal Effective Date
(Required)
MM slash DD slash YYYY
Purchase Completion Date
(Required)
MM slash DD slash YYYY
(New purchases only)
