Assumption Simplified Mutual Life Insurance Company(ASSUS)- Online Application

PROPOSED INSURED

This field is hidden when viewing the form

Product Code

This field is hidden when viewing the form

Term Coverage

This field is hidden when viewing the form

Monthly Premium

This field is hidden when viewing the form

Coverage Amount2

This field is hidden when viewing the form

Sex

This field is hidden when viewing the form

Term, Permanent , I am not sure

Term

Permanent

I'm not sure

Simplified Triggered - QC Ignore this

Name

First Name*

Last Name*

Maiden Name (if applicable)

Address

No.*

Street*

Apartment No.*

PO Box*

City/Town*

Province*

Postal Code*

Date of Birth

Province of Birth*

Country of Birth*

Date of Birth*

Gender*

Male

Female

Gender*

Male

Female

This field is hidden when viewing the form

Age

Present residency status in Canada:*

Canadian citizen

Permanent resident (landed immigrant)

Other

Please specify*

Indicate date of status*

Social Insurance Number*

Contact Information

Phone Number*

Work phone*

Email Address*

Smoker Status

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

No

*Please verify the date of birth of the Proposed Insured by means of an original identification document.

Owner

Owner Information

Owner is:*

Insured

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

First name*

Last name*

Relationship to proposed insured*

No.*

Street*

Apartment No.*

PO Box*

City/Town*

Province*

Postal Code*

Date of Birth*

Gender*

Male

Female

Social Insurance Number*

Home Phone*

Work phone*

Email*

Declaration of Tax Residency

Select all that applies:

Untitled

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

No

Untitled2

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, select reason:*

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 Beneficiary do you have ?*

First name*

Last name*

Relationship to the Proposed Insured*

Status*

Revocable

Irrevocable

Age*

Share (%)*

First name*

Last name*

Relationship to the 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 ?*

First name*

Last name*

Relationship to the Proposed Insured*

Status*

Revocable

Irrevocable

Age*

Share (%)*

First name*

Last name*

Relationship to the 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:

Declaration of Insurability

Declaration of Insurability for Platinum Protection. All 19 Questions must be Answered "No".

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

Yes

No

You must obtain the height and weight information of the applicant for Lia

Height*

Weight*

Height		Weight		Height		Weight		Height		Weight
Ft/in	cm	lb	kg	Ft/in	cm	lb	kg	Ft/in	cm	lb	kg
4' 10"	147	192	87	5' 6"	168	247	112	6' 2"	188	310	141
4' 11"	150	198	90	5' 7"	170	254	115	6' 3"	191	318	144
5' 0"	152	205	93	5' 8"	173	262	119	6' 4"	193	326	148
5' 1"	155	212	96	5' 9"	175	270	122	6' 5"	196	334	151
5' 2"	157	219	99	5' 10"	178	278	126	6' 6"	198	342	155
5' 3"	160	226	103	5' 11"	180	286	130	6' 7"	201	350	159
5' 4"	163	233	106	6' 0"	183	294	133	6' 8"	203	358	162
5' 5"	165	240	109	6' 1"	185	302	137	6' 9"	206	366	166

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)?*

Yes

No

3. 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?*

Yes

No

4. 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)?*

Yes

No

5. 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?*

Yes

No

6. Question for insured age 50 or under ONLY. Do you have a biological family member (father, mother, brother, sister), who was diagnosed with Huntington’s disease or polycystic kidney disease, and for which you have not been investigated for these diseases? *

6. Question for insured age 50 or under ONLY. Do you have a biological family member (father, mother, brother, sister), who was diagnosed with Huntington’s disease or polycystic kidney disease, and for which you have not been investigated for these diseases?*

Yes

No

7. In the past ten (10) 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?*

Yes

No

8. In the past five (5) 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)?*

Yes

No

9. In the past five (5) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for leukemia or cancer (other than basal cell carcinoma)?*

Yes

No

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

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

Yes

No

11. 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?*

Yes

No

12. In the past two (2) years, have you been: (a) Hospitalized for any respiratory disorder? (b) Treated with oral Prednisone or other oral corticosteroid for any respiratory disorder?*

Yes

No

13. In the past ten (10) 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?*

Yes

No

14. In the past five (5) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: (a) Convulsions, epilepsy, transient ischemic attack (TIA or mini-stroke), a spinal cord or brain tumor? (b) Bipolar disorder, schizophrenia, or psychosis? (c) Multiple sclerosis or Parkinson’s disease? (d) Rheumatoid arthritis or paralysis? e) Heart murmur or arrhythmia? (f) Crohn’s disease or ulcerative colitis? (g) Glomerulonephritis, scleroderma or Systemic Lupus Erythematosus (SLE)?*

Yes

No

15. Is your driver’s license currently suspended or revoked as a result of any driving infractions?*

Yes

No

16. In the past three (3) years, have you: (a) Used narcotics, barbiturates or steroids (other than prescribed by a physician)? (b) Used any unprescribed drugs (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?*

Yes

No

17. In the past three (3) months, have you required a new medication for high blood pressure or an increase in the dosage of any medication for high blood pressure?*

Yes

No

18. In the next twelve (12) months, do you expect or plan to travel outside North America, the Caribbean (excluding Haiti), or Western Europe for more than six (6) weeks?*

Yes

No

19. In the next twelve (12) months, do you expect or plan to engage in any hazardous sports or activities, or aerial flights other than as a passenger, commercial pilot, or crew member of a commercial flight?*

Yes

No

This field is hidden when viewing the form

Plat Product Parameter

You're not eligible for Platinum , Proceed to the next Golden Elite Category.

Declaration of Insurability for Golden Protection Elite. All 18 Questions must be Answered "No".

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

Yes

No

You must obtain the height and weight information of the applicant for Lia

Height*

Weight*

Height		Weight		Height		Weight		Height		Weight
Ft/in	cm	lb	kg	Ft/in	cm	lb	kg	Ft/in	cm	lb	kg
4' 10"	147	192	87	5' 6"	168	247	112	6' 2"	188	310	141
4' 11"	150	198	90	5' 7"	170	254	115	6' 3"	191	318	144
5' 0"	152	205	93	5' 8"	173	262	119	6' 4"	193	326	148
5' 1"	155	212	96	5' 9"	175	270	122	6' 5"	196	334	151
5' 2"	157	219	99	5' 10"	178	278	126	6' 6"	198	342	155
5' 3"	160	226	103	5' 11"	180	286	130	6' 7"	201	350	159
5' 4"	163	233	106	6' 0"	183	294	133	6' 8"	203	358	162
5' 5"	165	240	109	6' 1"	185	302	137	6' 9"	206	366	166

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)?*

Yes

No

3. 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?*

Yes

No

4. 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)?*

Yes

No

5. 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?*

Yes

No

6. Question for insured age 50 or under ONLY. Do you have a biological family member (father, mother, brother, sister), who was diagnosed with Huntington’s disease or polycystic kidney disease, and for which you have not been investigated for these diseases? *

6. Question for insured age 50 or under ONLY - Do you have a biological family member (father, mother, brother, sister), who was diagnosed with Huntington’s disease or polycystic kidney disease, and for which you have not been investigated for these diseases?

Yes

No

7. In the past ten (10) 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?*

Yes

No

8. In the past five (5) 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)?*

Yes

No

9. In the past five (5) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for leukemia or cancer (other than basal cell carcinoma)?*

Yes

No

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

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

Yes

No

11. 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?*

Yes

No

12. In the past two (2) years, have you been: (a) Hospitalized for any respiratory disorder? (b) Treated with oral Prednisone or other oral corticosteroid for any respiratory disorder?*

Yes

No

13. In the past five (5) 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?*

Yes

No

14. In the past three (3) years, have you been diagnosed with, hospitalized for, or undergone treatment (including medication) for any of the following conditions: (a) Convulsions, epilepsy, transient ischemic attack (TIA or mini-stroke), a spinal cord or brain tumor? (b) Bipolar disorder, schizophrenia, or psychosis? (c) Multiple sclerosis or Parkinson’s disease? (d) Rheumatoid arthritis or paralysis? (e) Heart murmur or arrhythmia? (f) Crohn’s disease or ulcerative colitis? (g) Glomerulonephritis, scleroderma or Systemic Lupus Erythematosus (SLE)?*

Yes

No

15. Is your driver’s license currently suspended or revoked as a result of any driving infractions?*

Yes

No

16. In the past three (3) years, have you: (a) Used narcotics, barbiturates or steroids (other than prescribed by a physician)? (b) Used any unprescribed drugs (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?*

Yes

No

17. In the next twelve (12) months, do you expect or plan to travel outside North America, the Caribbean (excluding Haiti), or Western Europe for more than twelve (12) weeks?*

Yes

No

18. In the next twelve (12) months, do you expect or plan to engage in any hazardous sports or activities, or aerial ﬂights other than as a passenger, commercial pilot, or crew member of a commercial ﬂight?*

Yes

No

This field is hidden when viewing the form

GE Product Parameter

You're not eligible for Golden Elite, Proceed to the next Golden Category.

Declaration of Insurability for Golden Protection. All 13 Questions must be Answered "No".

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

Yes

No

You must obtain the height and weight information of the applicant for Lia

Height*

Weight*

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	87	5' 6"	168	264	120	6' 2"	188	330	150
4' 11"	150	213	90	5' 7"	170	272	123	6' 3"	191	339	154
5' 0"	152	220	93	5' 8"	173	280	127	6' 4"	193	348	158
5' 1"	155	227	96	5' 9"	175	288	131	6' 5"	196	357	162
5' 2"	157	234	99	5' 10"	178	296	134	6' 6"	198	366	166
5' 3"	160	241	103	5' 11"	180	304	138	6' 7"	201	375	170
5' 4"	163	248	106	6' 0"	183	312	142	6' 8"	203	384	174
5' 5"	165	256	109	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)?*

Yes

No

3. 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?*

Yes

No

4. 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)?*

Yes

No

5. 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?*

Yes

No

6. 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?*

Yes

No

7. 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)?*

Yes

No

8. 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)?*

Yes

No

9. 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?*

Yes

No

10. 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?*

Yes

No

11. 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?*

Yes

No

12. 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?*

Yes

No

13. In the past two (2) years, have you: (a) Used narcotics, barbiturates or steroids (other than prescribed by a physician)? (b) Used any unprescribed drugs (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?*

Yes

No

This field is hidden when viewing the form

G Product Parameter

You're not eligible for Golden , Proceed to the next Silver Category.

Declaration of Insurability for Silver Protection. All 8 Questions must be Answered "No".

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

Yes

No

You must obtain the height and weight information of the applicant for Lia

Height*

Weight*

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?*

Yes

No

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)?*

Yes

No

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?*

Yes

No

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?*

Yes

No

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)?*

Yes

No

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)?*

Yes

No

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?*

Yes

No

This field is hidden when viewing the form

S Product Parameter

PROPOSED INSURED

Owner

Declaration of Tax Residency

Beneficiary Designation

Declaration of Insurability

Declaration of Insurability for Platinum Protection. All 19 Questions must be Answered "No".

You're not eligible for Platinum , Proceed to the next Golden Elite Category.

Declaration of Insurability for Golden Protection Elite. All 18 Questions must be Answered "No".

You're not eligible for Golden Elite, Proceed to the next Golden Category.

Declaration of Insurability for Golden Protection. All 13 Questions must be Answered "No".

You're not eligible for Golden , Proceed to the next Silver Category.

Declaration of Insurability for Silver Protection. All 8 Questions must be Answered "No".

Platinum Protection Whole Life

Coverage Status : Immediate

Coverage Status : Immediate

Coverage Status : Immediate

Golden Protection Elite Whole Life

Coverage Status : Immediate

Coverage Status : Immediate

Coverage Status : Immediate

Golden Protection

Coverage Status : Immediate

Coverage Status : Immediate

Coverage Status : Immediate

Silver Protection

Coverage Status : Deferred

Coverage Status : Deferred

Coverage Status : Deferred

Platinum Protection Term

Coverage Status : Immediate

Golden Protection Elite Term

Coverage Status : Immediate

Section Break