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Field of Activity
what field do you work in?
Employment Status
Salaried Employee
Contract Worker
Self Employed
Do You Contribute to Unemployment Insurance?
Yes
No
Do You Contribute to WSIB?
No
Yes
Hoe Long Have You Been Self-Employed?
Less Than 1 Year
1 to 2 Years
3 -5 Years
5 - 10 Years
10+ Years
Hoe Long Have You Been with Your Current Employer?
Less Than 1 Year
1 to 2 Years
3 -5 Years
5 - 10 Years
10+ Years
Last Years Net Income
$0 - $20,000
$20,000 - $25,000
$25,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 - $65,000
$65,000 - $80,000
$80,000 - $100,000
$100,000 - $125,000
$125,000 - $150,000
$150,000 - $200,000
$200,000 - $250,000
$250,000+
I prefer not to say
Net Income the Year Before Last
$0 - $20,000
$20,000 - $25,000
$25,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
$50,000 - $65,000
$65,000 - $80,000
$80,000 - $100,000
$100,000 - $125,000
$125,000 - $150,000
$150,000 - $200,000
$200,000 - $250,000
$250,000+
I prefer not to say
What Percentage of Your Income Would You Like to Cover?
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Do You Have Medical Complications?
No
Yes
I Prefer Not to Say
Details of Medical Complications
Condition, Duration of Treatment, Initial Occurrence, Last Medical Visit, Last Medical Prognosis, Prescription Medical Details...
Have You Ever Been Unable to Practice Your Occupation For More Than 2 Weeks Because of Disability?
No
Yes
Details of Disability
Date of Occurrence, Duration of Disability, Medical Condition, Treatments, Final Prognosis
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