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"Do you currently have, have you ever had, been told you had or received treatment or advice for:"
Health Information
1. Abnormal blood pressure, coronary artery disease, elevated cholesterol, heart murmur, Transient Ischemic Attack (TIA) stroke or any other disorder or disease of the heart, blood vessels or cardiovascular systems? Yes No
2. Cancer, tumor, polyp or any other growth of malignancy? Yes No
3. Diabetes, thyroid disorder, anemia, hepatitis, or hepatitis carrier state, or any other blood or glandular disorder or disease? Yes No
4. a nose. throat, lung or any other respiratory disorder or disease? Yes No
5. a disorder or disease of the stomach, intestines, rectum, liver or pancreas? Yes No
6. an injury to, or disorder or disease of the bones, muscles, joints, eyes, ears or skin? Yes No
7. Amyotrophic Lateral Sclerosis(ALS/Lou Gehrig's Disease), Motor Neuron Disease, Huntington,s Chorea, Multiple Sclerosis, epilepsy, seizures, brain disorder, or any other disorder or disease of the nervous system? Yes No
8. Anxiety, depression, chronic fatigue, suicide ideation, or an emotional, behavioral, mental or nervous disorder or disease? Yes No
9. Abnormal PSA, mammogram, or PAP smear or a disorder or disease of the kidney, bladder, or genital organs or system? Yes No
10. AIDS (Acquired Immune Deficiency Syndrome), positive HIV test, or another immunological disorder or disease? Yes No
11. Have you ever been under observation, had medical or surgical advice or treatment, or been hospitalized for a disorder, disease, or for an injury or illness not mentioned above? Yes No
12. Have you ever requested or receive a pension, benefit or payment because of a disorder, disease, injury or illness? Yes No
13. Are you now under medical observation, investigation or taking medical treatment? Yes No
14. Are you aware of a symptom, injury, illness or complaint that you have not yet consulted a physician about or for which a test, consultation or treatment has been recommended or scheduled but not yet been completed or the results of which are not yet known? Yes No
15. Have any of your immediate family members(father, mother, siblings) had Heart Disease, Stroke, Cancer(specify type), Diabetes, Kidney Disease, Mental Illness, Alcoholism, Huntington,s Chorea, Amyotrophic Lateral Sclerosis (ALS/Lou Gehrig’s Disease), Parkinson’s Disease, Motor Neuron
Disease, Multiple Sclerosis, Alzheimer’s Disease, or any hereditary disorder or disease?		 Yes No
16. Have you ever used cocaine, marijuana, hashish, narcotics, or other hallucinogenic, habit forming, or illicit drugs? Yes No
17. Do you have any individual life or critical illness insurance in effect? Yes No
18. Is the Insurance applied for in this application intended to replace or significantly change any life, critical illness insurance("CI") or disability income ("DI") insurance? Yes No
19. At this life do you have any other applications for life, critical illness or disability income insurance pending? Yes No
20. Have you operated an aircraft or been a member of an aircrew in the past 5 years or do you intend to do so in the future? Yes No
21. Within the past 2 years have you engaged in or do you have plan to engage in any of the following: Scuba diving, mountain climbing, hang gliding, parachute jumping, racing cars, boats or other motorized vehicles or any other hazardous sport or activity? Yes No
22. During the past 12 months have you traveled, resided or worked outside North America? Yes No
23. Within the next 12 months do you intended to travel, reside or work outside of North America? Yes No
24. Have you ever had an application for life, critical illness or disability income insurance declined or postponed, or been offered insurance with restrictions or rates that were not standard? Yes No
25. Provide your Driver's License number and where it was issued:
a) Driver's License Number Issuing jurisdiction		  
b) Within the past 3 years have you been convicted of , or are you currently charged wih, any moving traffic violation(s) or has your drivers license been under suspension or revoked? Yes No
c) Within the past 10 years have you been convicted of either impaired driving or refusal to provide a breath sample? Yes No
26. Have you been convicted of any criminal offence in the past 5 years or do you have any criminal charges pending? Yes No
27. Personal Physician (if none, list physicians or clinics consulted in the past 5 years):  
Name Address City/Province
Last visit to the doctor? Reason for visit Tratment Prescribed
28. What is your Height or Weight?
Height Weight 		 


Privacy Policy by TRUSTe
Privacy Policy by TRUSTe
We are a broker company offering plans / insurance products from companies like Manulife Financial, RBC Insurance, Sun life, Industrial Alliance, Assumption Life, Empire Life and many more, what we care for is a plan that best suits your needs at lowest possible premiums. We work in the best interest of client and not insurance companies. We strive to maintain the accuracy with all the information provided on this website; however errors and omissions regretted.

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