Form

PERSONAL INFORMATION

Patient Name

Patient Home address

Have any of your family members been treated for cancer, heart disease, stroke or an aneurysm prior to the age of 60?: (required)

*Select

Yes

No

What kind of insurance will you apply for? (required)

Life Insurance/Travel and Visa

Business Insurance

Farm Insurance

Residential Insurance

(required)

1 YEAR PLAN______$550 (CAD)

2 YEARS PLAN______ $1000(CAD)

5 YEARS PLAN___ $2500 (CAD)

1 YEAR FAMILY PLAN_____ $900 (CAD)

2 YEARS FAMILY PLAN___ $1600 (CAD)

5 YEARS FAMILY PLAN____$6000 (CAD)