Assumption Mutual Life Insurance Company(ASSU)- Online Application

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Step 1 of 7

14%

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Coverage Amount

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Age

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Smoker

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Product Code

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Term Coverage

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Monthly Premium

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Sex

Proposed Insured

Life Triggered - QC Ignore this

First Name*

Last Name*

Maiden Name (if applicable)

Address

Street*

City/Town*

Postal code*

Province*

Province of Birth*

Country of Birth*

Date of Birth*

Day

Month

Year

Gender*

Male

Female

Gender*

Male

Female

Present residency status in Canada*

Canadian citizen

Permanent resident (landed immigrant)

Other

Please specify*

Indicate date of status*

Day

Month

Year

Social Insurance Number*

Phone Number*

Work phone

Email Address*

In the past twelve (12) months, have you used any substance or product containing tobacco, nicotine, or marijuana mixed with nicotine, or used e-cigarettes?*

Yes

Owner

Owner is:*

Insured

Other (Body Corporate or other than Proposed Insured named above)

First*

Last*

Relationship to Proposed insured*

Address

Street*

City/Town*

Province*

Postal Code*

Date of Birth*

Day

Month

Year

Gender*

Male

Female

Social Insurance Number*

Home phone*

Work phone

Email*

Declaration of Tax Residency

Select all that applies

Owner is a tax resident or a citizen of the United States

Taxpayer identiﬁcation number (TIN) from the United States*

If the owner does not have a TIN from the United States, please note that he/she will have to apply for a TIN within the next 90 days following the submission of the application. Once the TIN is received, does the owner agree to provide the TIN to Assumption Life within 15 days of its receipt?*

Yes

Non-USA

Owner is a tax resident of a jurisdiction other than Canada or the United States

Jurisdiction*

Taxpayer identiﬁcation number (TIN):*

If owner does not have a TIN for a speciﬁc jurisdiction*

Application is in progress/Will apply within 90 days

Jurisdiction of tax residence does not issue TINs

Other reason

Beneficiary Designation

* Total % share must equal 100% for Primary and 100% for Contingent Beneficiaries.

Primary Beneficiary

How many Primary Beneficiaries do you have ?*

Primary Beneficiary 1 First Name*

Primary Beneficiary 1 Last Name*

Relationship to Proposed insured*

Status*

Revocable

Irrevocable

Age*

Share (%)*

Primary Beneficiary 2 First Name*

Primary Beneficiary 2 Last Name*

Relationship to Proposed insured*

Status*

Revocable

Irrevocable

Age*

Share (%)*

* Total % share must equal 100% for Primary Beneficiaries.

Contingent Beneficiary (Upon death of all primary and substitute beneﬁciaries)

How many Contingent Beneficiaries do you have ? (Upon death of all primary and substitute beneﬁciaries)*

Contingent Beneficiary 1 First Name*

Contingent Beneficiary 1 Last Name*

Relationship to Proposed insured*

Status*

Revocable

Irrevocable

Age*

Share (%)*

Contingent Beneficiary 2 First Name*

Contingent Beneficiary 2 Last Name*

Relationship to Proposed insured*

Status*

Revocable

Irrevocable

Age*

Share (%)*

* Total % share must equal 100% for Contingent Beneficiaries.

Assign a trustee (Optional)

If the Beneficiary is a minor, please designate a Trustee:

Relationship of the Trustee to the Beneficiary:

Insurance Replacement

Is the insurance requested intended to replace an existing individual life insurance?

Yes*

*If Yes, please ensure that you satisfy the Proposed Insured’s province’s disclosure requirements pertaining to the replacement of a life insurance policy. Moreover, if the original policy being replaced is with Assumption Life, a written notice or a "policy service request" signed by the owner of the original policy must be sent to Assumption Life in order to terminate the existing policy.

SECTION 1 - GOLDEN PROTECTION

You must obtain the height and weight information of the applicant

Height*

Weight*

1. Does your weight exceed the weight corresponding to your height in the following table? *

Gold ans1*

Yes

Height		Weight		Height		Weight		Height		Weight
Ft/in	cm	lb	kg	Ft/in	cm	lb	kg	Ft/in	cm	lb	kg
4' 10"	147	206	93	5' 6"	168	264	120	6' 2"	188	330	150
4' 11"	150	213	97	5' 7"	170	272	123	6' 3"	191	339	154
5' 0"	152	220	100	5' 8"	173	280	127	6' 4"	193	348	158
5' 1"	155	227	103	5' 9"	175	288	131	6' 5"	196	357	162
5' 2"	157	234	106	5' 10"	178	296	134	6' 6"	198	366	166
5' 3"	160	241	109	5' 11"	180	304	138	6' 7"	201	375	170
5' 4"	163	248	112	6' 0"	183	312	142	6' 8"	203	384	174
5' 5"	165	256	116	6' 1"	185	321	146	6' 9"	206	393	178

2. In the past twelve (12) months, have you lost more than 10% of your current body weight (other than due to pregnancy, intentional dieting or exercise)? *

Gold ans2*

Yes

3. In the past three (3) years, have you been diagnosed with or hospitalized for:: (a) Chronic kidney disease or polycystic kidney disease (PKD) or undergone dialysis?; (b) Angina or a heart attack or undergone coronary angioplasty (with or without a stent insertion) or coronary artery bypass surgery?; (c) Cerebrovascular accident (stroke)? *

Gold ans3*

Yes

4. In the past three (3) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for leukemia or cancer (other than basal cell carcinoma)? *

Gold ans4*

Yes

5. Have you ever been diagnosed with diabetes (other than gestational diabetes) and had any of the following conditions in the past three (3) years:: (a) Heart attack?; (b) Angina?; (c) Cerebrovascular accident (stroke)?; (d) Peripheral vascular disease?; (e) Gangrene?; (f) Amputation?; (g) Hypoglycemic coma? *

Gold ans5*

Yes

6. In the past ten (10) years, have you been diagnosed with a chronic respiratory disorder (other than sleep apnea) that required the administration of oxygen? *

Gold ans6*

Yes

7. In the past twelve (12) months, have you been:: (a) Hospitalized for any respiratory disorder?; (b) Treated with oral Prednisone or other oral corticosteroid for any respiratory disorder? *

Gold ans7*

Yes

8. In the past three (3) years, have you been diagnosed with or hospitalized for:: (a) Hepatitis B or C?; (b) Cirrhosis of the liver?; (c) Chronic pancreatitis?; (d) Two (2) or more episodes of acute pancreatitis? *

Gold ans8*

Yes

9. In the past two (2) years, have you:: (a) Used narcotics, barbiturates or steroids (other than prescribed by a physician)?; (b)Used any drugs unprescribed (other than marijuana products or over the counter medications), including but not limited to cocaine, LSD, amphetamines, hallucinogens?; (c) Used any prescribed or non-prescribed marijuana products more than 6 times per week?; (d)Been advised by a health professional to discontinue your consumption of alcohol or drugs, or have you received advice or undergone treatment (including medication) for alcohol or drug abuse?; (e) Been accused or charged with an alcohol-related or a drug-related driving offence or refused a breathalyzer?; (f) Been incarcerated, convicted of a crime or violation of any law, or are you currently accused of a crime or violation of any law for which a verdict has not yet been rendered? *

Gold ans9*

Yes

You don't qualify for Golden Protection but you have qualified for Silver Protection up to $50,000,please proceed to SECTION 2 located on the following page to qualify for coverage of up to $50,000 with Silver Protection.

You’ve qualified for Golden Protection up to $100,000, please proceed to the next page to confirm product and sum insured

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SECTION 2 - SILVER PROTECTION

You must obtain the height and weight information of the applicant

Height*

Weight*

1. Does your weight exceed the weight corresponding to your height in the following table? *

Silver ans1*

Yes

Height		Weight		Height		Weight		Height		Weight
Ft/in	cm	lb	kg	Ft/in	cm	lb	kg	Ft/in	cm	lb	kg
4' 10"	147	236	107	5' 6"	168	303	137	6' 2"	188	379	172
4' 11"	150	244	110	5' 7"	170	312	142	6' 3"	191	389	176
5' 0"	152	252	114	5' 8"	173	321	146	6' 4"	193	399	181
5' 1"	155	260	118	5' 9"	175	330	150	6' 5"	196	409	186
5' 2"	157	268	122	5' 10"	178	339	154	6' 6"	198	419	190
5' 3"	160	276	125	5' 11"	180	349	158	6' 7"	201	429	195
5' 4"	163	285	129	6' 0"	183	359	163	6' 8"	203	439	199
5' 5"	165	294	133	6' 1"	185	369	167	6' 9"	206	449	204

2. Are you currently:: (a) Admitted to a hospital?; (b) Residing or are you on a waiting list to reside in a long-term care facility, nursing home, skilled nursing facility or any other facility requiring care of a skilled staff? *

Silver ans2*

Yes

3. Are you aware of any signs, symptoms, or any abnormal diagnostic test for which:: (a) You have not yet consulted a physician?; (b) You are currently being investigated?; (c) You have a pending consultation with a medical specialist? (Medical specialist does not include a general practitioner and pending consultation does not include a routine follow-up.); (d) You have consulted with medical specialist without having received a diagnosis?; (e) You are currently awaiting for a surgery (other than day surgery/outpatient surgery)? *

Silver ans3*

Yes

4. Have you ever:: (a) Been diagnosed with, hospitalized for, or undergone treatment (including medication) for cystic ﬁbrosis, HIV, AIDS, or AIDS-related complex?; (b) Been diagnosed with or undergone treatment (including medication) for muscular dystrophy, Huntington’s disease, amyotrophic lateral sclerosis (Lou Gehrig’s disease), Alzheimer’s disease, or dementia?; (c) Been advised by a physician that you have a terminal illness for which you are currently receiving Palliative or Hospice care or have discussed this type of care with a health professional? *

Silver ans4*

Yes

5. In the past five (5) years, have you:: (a) Received a bone marrow transplant or an organ transplant (other than a corneal transplant) or were you advised that one was required?; (b) Been diagnosed with or hospitalized for congestive heart failure or cardiomyopathy? *

Silver ans5*

Yes

6. In the past two (2) years, have you been diagnosed with or hospitalized for:: (a) Chronic kidney disease or polycystic kidney disease (PKD) or undergone dialysis?; (b) Angina or a heart attack or undergone coronary angioplasty (with or without a stent insertion) or coronary artery bypass surgery?; (c) Cerebrovascular accident (stroke)? *

Silver ans6*

Yes

7. In the past two (2) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for leukemia or cancer (other than basal cell carcinoma)? *

Silver ans7*

Yes

8. In the past twelve (12) months, have you been advised by a health professional to discontinue your consumption of alcohol or drugs, or have you received advice or undergone treatment (including medication) for alcohol or drug abuse? *

Silver ans8*

Yes

If you answered "Yes" to any of the above questions,
you do not qualify for any of our Simplified Issue products.

You have qualified for Silver Protection up to $50,000, please proceed to the following page to qualify for coverage of up to $50,000 with Golden Protection.

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