Name

Email Address

Phone

Age

Smoker? Smoker? Yes No

Sex SexMaleFemaleOther

Health Class Health ClassBest Class / Preferred Plus (excellent health)Preferred (excellent health with minor issues)Standard Plus (better than average health)Standard (average health)

Amount Amount$10K$300K$500K$1M$5M

Province ProvinceONABBCMBNBNLNSPEQCSK

Type of Insurance Type of Insurance10 Year Term20 Year Term25 Year Term30 Year TermTerm to Age 65Whole LifeUniversal