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Life Insurance

What if you couldn't be there to take care of your family? Take away that worry and make sure that your family is well cared for after your gone with quality life insurance. Talk to one of our brokers today on the coverage that is right for you and your family.

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Personal Information

First Name Last Name
Date of Birth Occupation
Address Email

My Health Is:

Do you have a spouse? YesNo

Spouse First Name Spouse Last Name
Spouse Date of Birth Spouse Occupation

My Spouse's Health Is:

Home Phone (required) Mobile Phone (required) Preferred Contact Method
Home PhoneCell PhoneEmail
Combined Household Income Between $25K-$45KBetween $50K-$85KOver $100K

Dependent Information

Do you have any dependents? YesNo

People Financially Dependent on you.


Do you have any children? YesNo

Number of Children
If not now, are you planning to have children in the next 5 years? YesNo
Smoker/Non-Smoker Height Weight

Are you currently taking any medication? YesNo

If yes, please list your medications.

Do you have a family doctor? YesNo

If yes, enter your doctor's name.

When was your last visit to your GP?

Do you currently have life insurance? YesNo

If yes, how much coverage?

Do you currently have critical illness coverage? YesNo

If yes, how much coverage?

Do you currently have disability coverage? YesNo

If yes, what is your monthly benefit?

Do you plan to travel outside North America in the next 12 months? YesNo

If yes, where will you be traveling?

Planning Concerns

Please check the box that most appropriately reflects your views on each statement.
Y=Yes N=No ?=Not Sure X=Not Applicable
1. I am concerned about the ability of creditors, or others, to gain access to my personal assets. YN?X
2. I understand how I will be taxed on the disposition, or deemed disposition of my assets. YN?X
3. I am concerned about my ability to meet my income needs when I retire. YN?X
4. My spouse and I have sufficient personal income replacement Insurance to cover the risks and expenses of a disability. YN?X
5. I am concerned about the cost of long-term health care. YN?X
6. I am taking full advantage of tax-sheltered growth Opportunities within my life insurance programs. YN?X
7. I am concerned about the impact of market volatility on my retirement plans. YN?X
8. I have an investment holding and/or operating company. YN?X
Comments or Concerns