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Name: |
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| Email
Address: |
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| Address:
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| City:
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| Province:
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| Postal
Code: |
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| Phone
Number: |
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| Occupation:
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| Gender: |
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| Date
of birth: |
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| Height: |
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| Weight: |
pounds |
| Amount
of coverage? |
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| What
type of life insurance are you looking for? |
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| If
other, please describe the type of coverage you are looking
for: |
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The coverage
to be quoted will likely be:
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new coverage (I have none now)
additional coverage
replacement of existing coverage |
Tobacco/Nicotine
Use:
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Are you on any prescription medication? |
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| If
yes for what condition? |
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Do
you have, or have you ever had any health conditions such
as diabetes, cardiovascular disease, cancer, depression,
or surgeries? |
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Did any of your
parents or siblings have cardiovascular disease or cancer,
prior to age 60? |
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Yes
No |
Do
you engage in any hazardous activities such as private
piloting or scuba diving?
If so, please explain:
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In
the past 10 years, have you had any DUIs, or have you had
more than 2 driving violations in the past 3 years? |
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Yes
No |
Have
you ever been convicted of a felony? |
Yes
No |
Disclaimer
This is a request to provide a quote only and is not an
insurance policy. It is not an offer of insurance. Further
information may be required in order for a complete quote
to be provided. This quote request contains some information
about coverage offered but it does not list all of the conditions
and exclusions that apply to the described coverage. The
actual wording of the policy governs all situations. This
quote request is only available to persons resident in the
Province of Ontario. The products described are subject
to change without notice at any time. |
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