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Step
1
of 2
Type of Plan
Individual
Spousal
Name
*
First
Last
Phone
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Province
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Newfoundland
New Brunswick
Nova Scotia
Prince Edward Island
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
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Email
*
Age
Gender
Female
Male
Other
Smoker Status
Non Smoker
Smoker
Spouses Age
Spouses Gender
Female
Male
Other
Spouses Smoker Status
No Smoker
Smoker
Do You Know How Much Life Insurance You Need?
No
Yes
Next
How Much Life Insurance Would You Like?
Do You Have Children?
No
Yes
How Many Children Do You Have?
Age of the Eldest Child
Age of the Youngest Child
Do You Have a Mortgage?
No
Yes
Total Mortgage Amount
Time Left on Mortgage
Do You Have Any Outstanding Debt?
No
Yes
Amount of Outstanding Debt?
Would You Like to Leave an Inheritance?
No
Yes
How Much Inheritance Would You Like to Leave?
Do Any of the Applicants Have Health Complications?
No
Yes
I Prefer Not to Say
Details of Health Complications
Condition, Prognosis, Date of Last Medical Visit, Treatment...
Are Any of the Applicants on Any Prescription Medications?
No
Yes
I Prefer Not to Say
Details of Treatment/Medications
Name of Medication, Dosage, Condition, Duration of Treatment...
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