Health Questions

There are several plans available, answer the following questions to determine the best plan for you.

Is your weight outside the range for your height in following table?

4'8" — 4'10"	79 — 185 lbs	5'8" — 5'10"	115 — 260 lbs
4'11" — 5'1"	87 — 199 lbs	5'11" — 6'1"	125 — 282 lbs
5'2" — 5'4"	94 — 215 lbs	6'2" — 6'4"	139 — 305 lbs
5'5" — 5'7"	104 — 235 lbs	6'5" — 6'7"	149 — 333 lbs

4'8" — 4'10"	79 — 185 lbs
5'8" — 5'10"	115 — 260 lbs
4'11" — 5'1"	87 — 199 lbs
5'11" — 6'1"	125 — 282 lbs
5'2" — 5'4"	94 — 215 lbs
6'2" — 6'4"	139 — 305 lbs
5'5" — 5'7"	104 — 235 lbs
6'5" — 6'7"	149 — 333 lbs

Yes

Have you had a weight loss of 10% body weight or more within the last 12 months, other than due from intentional dieting, exercise, or child birth?

Yes

No
Are you currently incapable of independently carrying out five or more of the basic activities of daily living such as getting up (transferring), walking, washing, toileting, dressing or feeding?

Yes

No

Health Questions

Are you currently a resident of a long-term care facility, nursing home, nursing facility, or assisted living residence?

Yes

No
Are you in need of an organ transplant, on a waiting list for organ transplant or the recipient of an organ transplant (excluding corneal transplants)?

Yes

No
Have you been admitted to a hospital for more than 48 hours within the past 30 days (excluding pregnancy)?

Yes

No
Have you never been diagnosed for a condition for which a physician has estimated that you have 24 months or less to live?

Yes

No
Have you ever been told you have, or been treated for Acquired Immunodeficiency Syndrome (AIDS)?

Yes

No

Health Questions

Within the past 60 days, have you been advised by a physician of any abnormal diagnostic test result, to have surgery or a diagnostic test or special test of any type, or to consult with a physician, medical institution or specialist that has not yet been completed?

Yes

No
In the past 10 years, have you been told, been diagnosed with, or treated for, or advised to have an investigation, that has not been completed for:
1. Metastatic cancer or more than 1 occurrence of cancer?
  
  Yes
  
  No
2. Fibrosis, Cystic Fibrosis or a chronic respiratory condition (excluding sleep apnea) which required the continuing administration of oxygen?
  
  Yes
  
  No
3. Dementia, Alzheimer's, Muscular Dystrophy, Huntington's Chorea or Amyotrophic Lateral Sclerosis (ALS)?
  
  Yes
  
  No
4. Heart failure or cardiomyopathy?
  
  Yes
  
  No
Within the past three years, have you used narcotics or barbiturates (except as prescribed by a physician), heroin, psychoactive drugs, cocaine, crack or other similar agent, or been a resident of a drug or alcohol treatment facility?

Yes

No
1. Has it been in the past 12 months?
  
  Yes
  
  No
Have you ever had, been treated for, or been diagnosed prior to age 40, with: chronic kidney disease, stroke (CVA), transient ischemic attack (TIA), aneurysm, coronary artery disease, heart bypass surgery, angioplasty, stent insertion, angina or heart attack?

Yes

No
Within the past 12 months, have you been convicted of, awaiting sentencing for, incarcerated for, or on probation for a criminal offence, or do you currently have any criminal charges pending?

Yes

No

Health Questions

Within the past 3 years, have you been treated for or received medical advice or counseling for the use of drugs or alcohol?

Yes

No
Within the past 12 months have you experienced:
1. Cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, stroke (CVA), heart bypass surgery, angioplasty, stent insertion or more than one transient ischemic attack (TIA)?
  
  Yes
  
  No
2. Circulatory problems in the legs and/or feet (peripheral arterial or vascular disease)?
  
  Yes
  
  No
3. Chronic kidney disease, or been investigated or been advised to be investigated for polycystic kidney disease (PKD), or have a family history of PKD and have not been investigated?
  
  Yes
  
  No
4. Liver disease such as, but not limited to, cirrhosis or hepatitis (excluding Hepatitis A or B)?
  
  Yes
  
  No
Have you ever been told you have, treated for any form of cancer, leukemia or lymphoma (excluding basal cell carcinoma) in your life?

Yes

No
1. Was this treatment or diagnosed in the last 12 months?
  
  Yes
  
  No
2. In the past 3 years have you been told you have or received treatment for:
3. Lung cancer
  
  Yes
  
  No
4. Colon cancer
  
  Yes
  
  No
5. Breast cancer, cervical cancer, or uterine cancer?
  
  Yes
  
  No
6. Malignant melanoma
  
  Yes
  
  No
7. Leukemia (all types), lymphoma or multiple myeloma
  
  Yes
  
  No
Have you ever had, been told you had, been diagnosed with, or treated for diabetes (excluding gestational diabetes), or are undergoing investigation for diabetes or blood sugar levels?

Yes

No
1. Are you under the age of 30?
  
  Yes
  
  No
2. Are you under age 55 with diabetes that was diagnosed more than 20 years ago and is currently treated with insulin?
  
  Yes
  
  No
3. Do you have diabetes that is currently treated with insulin and the prescribed dosage of insulin increased within the past six months?
  
  Yes
  
  No
4. Have you ever had, been told you have, or been treated for diabetes and any of the following: coronary artery disease, peripheral vascular disease, tingling and loss of feeling in the extremities (neuropathy), amputation, retinopathy or stroke (CVA)?
  
  Yes
  
  No
5. Within the last 6 months, have you been told you have or been treated for diabetes?
  
  Yes
  
  No

Health Questions

In the past 12 months, have you had, been told you had, been diagnosed with or treated for bipolar disorder, or schizophrenia, or psychosis?

Yes

No
In the next 12 months, do you plan to travel outside North America, the Caribbean (excluding Haiti), the United Kingdom, or European Union countries for more than 12 consecutive weeks?

Yes

No
Are you age 54 or under and within the past three years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)?

Yes

No
Are you age 55 or over and within the past two years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)?

Yes

No

Health Questions

Within the past 3 years, have you been incarcerated or on probation for a criminal offence or are criminal charges now pending, excluding a single DUI?

Yes

No
Within the past two years, have you been involved in the operation of an aircraft as a pilot (scheduled commercial pilots excluded) or involved in any hazardous sports, or do you plan to do so within the next year?

Yes

No
Within the past two years, has your driver’s licence been suspended or revoked, or have you had more than three moving violations within the past 12 months?

Yes

No
In the past 12 months, have you been told you have, been treated for, or are you currently under investigation for multiple sclerosis?

Yes

No

Please provide the following information to obtain a quote

First Name:

Last Name:

Email:

Phone Number:

Birthday

Gender:

Citizenship:

Have you smoked or used nicotine products in the past year?

Name of Beneficiary

Which plan are you applying for?

How much insurance would you like?

Comments:

Get Free Quote

Funeral Insurance Program

A plan for everyone

Final Wish Guide

Personal Profile

Basic Information

Survivors Please list family members and their relationship:

Person to notify:

Legal Property (List location of documents)

***NOTE: Personal information such as S.I.N., Banking, Charge Cards, Safety Deposit Box, and Insurance with gray boxes that can't be filled, will be filled by pen once you received the printed copy of your profile

S.I.N #

Banking

Charge Cards

Safety Deposit Box

Funeral Arrangements:

Wake or Viewing

Place of Viewing

Service

Donation of Flowers

Music

Paulbearers

Clothing

Earth Burial/Casket:

Cremation

Urn:

Ashes to be

Headstone

Celebration of Life

Special mesasge to:

Dear Loved Ones,

Additional Comments:

Health Questions

Health Questions

Health Questions

Health Questions

Health Questions

Health Questions

Please provide the following information to obtain a quote

Please fix the following errors:

Congratulations, !

Monthly Fee:

Premium Financial Newsletter

Insurance

Quick links

Social