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Critical Illness Quote Form

Critical Illness Insurance – Pre-Quote Form

Full Name: Date of Birth: Gender: Province of Residence: Are you a Canadian citizen or permanent resident? Do you currently use tobacco, vape, or nicotine products? Have you ever been diagnosed with or treated for any of the following? Do you currently take any prescription medications? If yes, please list them: Do you have any current serious medical conditions? If yes, please describe: Has any immediate family member (parent or sibling) been diagnosed with any of the following before age 60?

Cancer Heart disease or stroke Diabetes No known family history

If applicable, specify relation and condition: Preferred Coverage Amount: Would you like a return of premium option (refund if no claim is made)?

Critical Illness Insurance – Pre-Quote Form

Life Insurance

Group Insurance

RRSP