Why we need this?

To prepare your quotes. You may even qualify for a premium discount.

Once you complete the on-line form and click on Send, we’ll be able to get back to you with the information you need.

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Required information
Last name		First name
Province of residence	- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon	Birth date yyyy/mm/dd
Sex	- Female Male	Telephone number (e.g. 514-499-7999)
Amount of insurance to convert		Email address
Smoking habits *	Yes     No
*Have you used any substance or product containing tobacco, nicotine (including the nicotin patch or gum), or marijuana in the last 12 months?

In order to determine if you qualify for a premium discount, please complete the following questions: (based on form 6652 - Application for Group Conversion).   Click to Skip

	Yes	No
Have you ever had an application for insurance rated, declined or postponed?
Is your weight either above or below for your height according to this table?
Have you lost more than 15 pounds in the last year without deliberately trying to do so through an adjustment in diet and/or exercise?
In the previous 5 years, have you:	Yes	No
Been advised to reduce consumption of alcohol, or drugs (prescription or otherwise)?
Been convicted of drinking while driving?
Used any illegal drugs, such as cocaine, or any narcotics?
Been off work for more than 2 consecutive weeks due to illness?
Have you ever had any known indication of, been treated for, or  received a recommendation for treatment of any of the following:	Yes	No
Heart or circulation problems, angina, heart attack, chest pain, stroke, diabetes?
Disorder of the kidney, lungs or genital organs including the prostate or breast?
Hepatitis or other condition of the liver, intestine, pancreas, or stomach?
Cancer, tumour, skin lesion, anaemia, blood disorder, haemophilia, or leukemia?
Disorder of the brain or nervous system?
Are you:	Yes	No
Presently awaiting, or been referred for, any medical consultation or medical tests (other than pre- or post-natal care)?
Presently awaiting any test results, or aware of any abnormal results?
Aware of any symptoms or complaints for which you have not yet sought medical advice?
Have you had, or been recommended to have, a test for HIV, received information  indicating possible exposure to HIV, or have you been told you may have any other immunological conditions?	Yes	No

Do you have a financial advisor?    Yes    No
Advisor name		Telephone number (e.g. 514-499-7999)
Address		Email address

Please click on Send to request your rates!

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