Life Insurance Quote Application

Company

Annual Premium

Monthly Premium

First Name*

Last Name*

Email*

Phone Number*

Are you canadian citizen?*

Where were you born?*

Personal health questionnaires

Have you ever been treated for or taken medication for high blood pressure?

Have you ever been treated for or taken medication for high cholesterol?

Do you have diabetes type 1 or type 2?

Are you taking any medications other than mentioned above?

Have you been told to do any diagnostic test that you haven’t done or you are currently awaiting surgery/outpatient surgery?

Family medical history

Had any in your immediate family (Mother, Father, Brother, Sister) been diagnosed with cardiovascular disease,(Heart attack or stroke) cancer, diabetes or kidney disease?