What is your primary motivation for seeking insurance today?

(Check all that apply)

Insurance Amount Requested *

Your Details

Who would you like to get coverage for?

What’s your gender?

Have you used nicotine or tobacco products in the last 12 months?

Enter your date of birth

Your Build

Your Height

Your weight

Tobacco Use

Smoker / Tobacco

Have you used any tobacco product(s) in the last 5 year? Select all that apply.

Blood Pressure

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

Cholesterol

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

Driving History

Have you been convicted of driving (DUI/DWI) or reckless driving, or hasyour licence been revoked or suspended ,or have you been involved in any accidents?

Occupation

What is your employment Status?

What is your employment status*

What is your current occupation?

What is your annual income?

$

Eligibility

Are you currently working? (Answer yes if you are currently receiving benefits from a parental leave plan)

In the past 12 months (or the 12 months prior to your parental leave if applicable), were you able to complete all your occupations (28 weeks, 21 hours/week) and on a regular basis?

In the past 2 years (or the 2 years prior to your parental leave if applicable), were you absent from work for more than 15 consecutive days due to illness or received disability or critical illness benefits from a private, group or public insurance plan?

In the past 2 years, did you receive treatment(including the participation in a support group), were you advised to reduce your consumption or seek treatment regarding the use of alcohol or drugs?

In the past 5 years, were you incarcerated for more than 48 hours?

In the past 6 months, did you have any physical or mental symptoms or discomfort for which you have not yet consulted a health professional?

Health

In the past 2 years, have you received a treatment or a therapy, been prescribed or taken prescription medication other than birth control, antibiotics or nonsteroidal anti-inflammatory drugs?

In the past 5 years, were you diagnosed with, received treatment for or recommended therapy or medication for any of the following disorders:

Heart, stroke (cerebrovascular accident) or blood vessel disorder excluding treated and controlled high blood pressure.

Cancer, tumour, cystic fibrosis, Hodgkin’s disease, lymphoma, leukemia, emphysema or chronic bronchitis?

Crohn’s disease, ulcerative colitis, hepatitis B or C, or other disorder of the liver or pancreas?

Diabetes, pre-diabetes or glucose intolerance?

Multiple sclerosis, muscular dystrophy or paralysis?

Seizures or motor neuron disease?

Prostate disorder, polycystic kidney disease or other kidney disorder?

Acquired immune deficiency syndrome (AIDS) or human immunodeficiency virus (HIV)?

Rheumatoid arthritis, fibromyalgia or spinal disc disease?

Depression, psychosis, schizophrenia or bipolar disorder?

Did more than one member of your family (parents, brothers or sisters) have cancer, diabetes, stroke, heart attack, angina, multiple sclerosis, polycystic kidney disease or motor neuron disease before age 60?

Your Details