This form is offered as a tool to assist you in expressing your final wishes. We welcome to use this form if it helps you, we do not offer any legal advice.
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
Is your weight greater than that indicated for your height in the following
table:
4'8" — 4'10"
230 lbs
5'8" — 5'10"
328 lbs
4'11" — 5'1"
247 lbs
5'11" — 6'1"
358 lbs
5'2" — 5'4"
273 lbs
6'2" — 6'4"
389 lbs
5'5" — 5'7"
300 lbs
6'5" — 6'7"
420 lbs
4'8" — 4'10"
230 lbs
5'8" — 5'10"
328 lbs
4'11" — 5'1"
247 lbs
5'11" — 6'1"
358 lbs
5'2" — 5'4"
273 lbs
6'2" — 6'4"
389 lbs
5'5" — 5'7"
300 lbs
6'5" — 6'7"
420 lbs
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?
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?
Health Questions
Are you currently a resident of a long-term care facility, nursing
home, nursing facility, or assisted living residence?
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)?
Have you been admitted to a hospital for more than 48 hours within
the past 30 days (excluding pregnancy)?
Have you never been diagnosed for a condition for which a physician
has estimated that you have 24 months or less to live?
Have you ever been told you have, or been treated for Acquired
Immunodeficiency Syndrome (AIDS)?
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?
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:
Metastatic cancer or more than 1 occurrence of cancer?
Fibrosis, Cystic Fibrosis or a chronic respiratory condition
(excluding sleep apnea) which required the continuing administration of oxygen?
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?
Has it been in the past 12 months?
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?
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?
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?
Within the past 12 months have you experienced:
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)?
Circulatory problems in the legs and/or feet (peripheral
arterial or vascular disease)?
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?
Liver disease such as, but not limited to, cirrhosis or
hepatitis (excluding Hepatitis A or B)?
Have you ever been told you have, treated for any form of cancer,
leukemia or lymphoma (excluding basal cell carcinoma) in your life?
Was this treatment or diagnosed in the last 12 months?
In the past 3 years have you been told you have or received
treatment for:
Lung cancer
Colon cancer
Breast cancer, cervical cancer, or uterine cancer?
Malignant melanoma
Leukemia (all types), lymphoma or multiple myeloma
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?
Are you under the age of 30?
Are you under age 55 with diabetes that was diagnosed more
than 20 years ago and is currently treated with insulin?
Do you have diabetes that is currently treated with insulin
and the prescribed dosage of insulin increased within the past six months?
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)?
Within the last 6 months, have you been told you have or been
treated for diabetes?
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?
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?
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)?
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)?
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?
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?
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?
In the past 12 months, have you been told you have, been treated for,
or are you currently under investigation for multiple sclerosis?
Please provide the following information to obtain a quote
Please fix the following errors:
Please enter a valid first name
Please enter a valid last name
Please enter a valid email address
Please enter a valid phone number
Please select a birth day
Please select a birth month
Please select a birth year
Please provide your gender
Please provide your citizenship
Please select if you have smoked or used nicotine products in the past year
Please enter a valid beneficiary
Please enter an insurance coverage amount less than or equal $500,000
Please do not enter special characters
Congratulations, !
Based on the information you provided, you may qualify for the Platinum plan.
Monthly Fee:
Please enter a coverage amount less than or
equal $500,000
Maximum Coverage Amount:$50,000
Thank you for providing your information, we will be in touch with you
shortly.
An agent will contact you to assist with the program.
