Canada Protection Plan (CPP) - Online Application

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Step 1 of 12

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Easy Passthrough related section

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smoker

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Product Code

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Term Coverage

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Coverage Amount Number

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Monthly Premium

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plan type

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Sex

INSURED

Must be a Canadian Citizen, Permanent Resident or with a valid work permit to apply. The maximum amount for an Insured on a work permit is $250,000.

SIN required only if the Insured will be the Owner and is applying for permanent life insurance (except for T100).

First Name*

Middle Name

Last Name*

Gender*

Male

Female

Gender*

Male

Female

Citizenship status*

Canadian Citizen

Permanent Resident

Work Permit

Country Of Birth*

Date of Birth*

Month

Day

Year

Email Address*

Phone Number*

Work/Other Phone

Address

Street Name & Number*

Apartment Number

City / Town*

Province/Territory*

Postal Code*

Best date and time to call for verification, if applicable (be specific).

Date

MM slash DD slash YYYY

Time

Hours

Minutes

AM/PM

Social Insurance Number*

Social Insurance Number

Occupation*

Driver's Licence (or Gov't Issued Photo ID # and Type)

Number (and type)*

Province/Territory of Issue*

Expiry Date*

MM slash DD slash YYYY

Are you a Foresters member?*

Yes

No, applying for membership

OWNER

Owner is*

Insured

Other

Full Legal Name, or Corporation/Entity*

Relationship to Insured*

If the Owner is a corporation, the signature must be accompanied by either the company name and title of the signing officer OR a company seal

Address

Street Name & Number*

Apartment Number

City / Town*

Province/Territory*

Postal Code*

Email*

Phone*

Work / Other Telephone

Driver's Licence (or Gov't Issued Photo ID # and Type)*

Province/Territory of Issue*

Expiry Date*

MM slash DD slash YYYY

SIN required only if applying for permanent life insurance (except for T100).

Social Insurance Number*

Social Insurance Number

CONTINGENT OWNER

Full Legal Name, or Corporation/Entity*

Relationship to Owner*

BENEFICIARY

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

Important: Each beneficiary is revocable unless indicated otherwise. However in Quebec, the designation of a legally married spouse of the Owner is irrevocable unless expressly indicated to be revocable.

How many Beneficiaries do you have ?*

Beneficiary 1 Name*

Beneficiary 1 Date of Birth*

MM slash DD slash YYYY

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Beneficiary 1-AgeCal

Beneficiary 1 Relationship to Insured (or to Owner in Quebec)*

Beneficiary 1 Share Percentage*

Revocable status*

Revocable

Irrevocable

Type*

Primary

Contingent

Beneficiary 2 Name*

Beneficiary 2 Date of Birth*

MM slash DD slash YYYY

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Beneficiary 2-AgeCal

Beneficiary 2 Relationship to Insured (or to Owner in Quebec)*

Beneficiary 2 Share Percentage*

Revocable status*

Revocable

Irrevocable

Type*

Primary

Contingent

Beneficiary 3 Name*

Beneficiary 3 Date of Birth*

MM slash DD slash YYYY

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Beneficiary 3-AgeCal

Beneficiary 3 Relationship to Insured (or to Owner in Quebec)*

Beneficiary 3 Share Percentage*

Revocable status*

Revocable

Irrevocable

Type*

Primary

Contingent

Beneficiary 4 Name*

Beneficiary 4 Date of Birth*

MM slash DD slash YYYY

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Beneficiary 4-AgeCal

Beneficiary 4 Relationship to Insured (or to Owner in Quebec)*

Beneficiary 4 Share Percentage*

Revocable status*

Revocable

Irrevocable

Type*

Primary

Contingent

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

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

If a beneficiary is a minor: In all provinces except Quebec, a trustee should be named to receive funds on the minor's behalf.

In Quebec, the proceeds payable to a minor will be paid to the parent(s) (or legal guardian, if applicable).

Trustee Name

Relationship to Owner

PAYOR

Payor is*

Insured

Owner

Other

Full Name*

Relationship to Insured*

Date of Birth*

MM slash DD slash YYYY

Street Name & Number*

Apartment Number

City / Town*

Province/Territory*

Postal Code*

OWNER'S U.S. TAX STATUS

Complete only if applying for permanent life insurance (except for T100).

Are you a U.S. resident for tax purposes or a U.S. citizen?*

Yes

If YES, provide your U.S. tax identification number*

ELIGIBILITY QUESTIONS:

For all Eligibility Questions, "You” and “Your” refer to the Insured. Complete these questions for all applications. Then continue to the next section.

Within the past 12 months, have you used by any means, a substance or product containing tobacco or nicotine (excluding cigars), or have you smoked (including electronic vaporizer or “vaping”) marijuana more than four times per week?*

Yes

Smoker rates applicable

Will premiums be stopped, or coverage be reduced or discontinued, on any existing life insurance coverage or annuity if the insurance applied for in this application is issued?*

Yes

State insurer, amount and plan, and complete the Comparison Disclosure Statement or Life Insurance Replacement Declaration required in your province.

Insurer*

Amount*

Plan*

ELIGIBILITY QUESTIONS:

Are you currently incapable of independently carrying out two or more of the basic activities of daily living such as getting up, walking, washing, toileting, dressing or feeding?*

Yes

Are you currently a resident of a nursing home or nursing facility (excluding assisted living residences, retirement homes or senior living facilities), and are you currently bedridden or wheelchair bound?*

Yes

Are you in need of an organ transplant, on a waiting list for an organ transplant or the recipient of an organ transplant (excluding corneal transplants)?*

Yes

Within the past 30 days, have you been admitted to a hospital for more than 48 hours (excluding pregnancy)?*

Yes

Within the past 60 days, have you been advised by a physician of any abnormal diagnostic tests?*

Yes

Within the past 60 days, have you been advised by a physician to have surgery or a diagnostic test or special test of any type?*

Yes

Within the past 60 days, have you been advised by a physician to consult with a physician, medical institution or specialist that has not yet been completed?*

Yes

Have you ever been diagnosed with a life threatening, critical or terminal condition for which a physician has estimated that you have 24 months or less to live?*

Yes

Have you ever had, been told you have, or been treated for Acquired Immunodeficiency Syndrome (AIDS) or have you ever tested positive for Immunodeficiency virus (HIV)?*

Yes

Within the past ten years, have you had, been told you have, been treated for, or been advised to have an investigation, that has not yet been completed, for Metastatic cancer or more than one occurrence of cancer (excluding basal cell carcinoma)?*

Yes

Within the past ten years, have you had, been told you have, been treated for, or been advised to have an investigation, that has not yet been completed, for Cystic Fibrosis or a chronic respiratory condition (excluding sleep apnea) which required the continuing administration of oxygen?*

Yes

Within the past ten years, have you had, been told you have, been treated for, or been advised to have an investigation, that has not yet been completed, for Dementia, Alzheimer's, Muscular Dystrophy, Huntington's Chorea or Amyotrophic Lateral Sclerosis (ALS)?*

Yes

Within the past ten years, have you had, been told you have, been treated for, or been advised to have an investigation, that has not yet been completed, for Congestive heart failure or cardiomyopathy?*

Yes

Have you ever had, been treated for, or been diagnosed prior to age 40, with: chronic kidney disease, stroke (CVA), transient ischemic attack (TIA), aneurysm, coronary artery disease, heart bypass surgery, angioplasty, stent insertion, angina or heart attack?*

Yes

Within the past 12 months, have you used narcotics or barbiturates (except as prescribed by a physician), heroin, psychoactive drugs, cocaine, crack or other similar agents, or been a resident of a drug or alcohol treatment facility?*

Yes

Within the past 12 months, have you been convicted of, awaiting sentencing for, incarcerated for, or on probation for a criminal offence; or do you currently have any criminal charges pending?*

Yes

Is your weight greater than that indicated for your height in the following table?*

Yes

Height		Weight
4’8” — 4’10”	142 — 147 cm	230 lbs	104 kg
4’11” — 5’1”	148 — 155 cm	247 lbs	112 kg
5’2” — 5’4”	156 — 163 cm	273 lbs	124 kg
5’5” — 5’7”	164 — 170 cm	300 lbs	136 kg
5’8” — 5’10”	171 — 178 cm	328 lbs	149 kg
5’11” — 6’1”	179 — 185 cm	358 lbs	162 kg
6’2” — 6’4”	186 — 193 cm	389 lbs	176 kg
6’5” — 6’7”	194 — 201 cm	420 lbs	191 kg

Given that you answered yes to this question, you should apply for Deferred Elite Plans with a Maximum coverage of $25,000. Please speak with a YAM Insurance representative for more information.
Please proceed to the following page to conﬁrm Coverage Details.

You’ve qualified for Guaranteed Acceptance Life with a maximum coverage of $25,000
Please proceed to the following page to qualify for coverage of Maximum $75,000 with Deferred Life.

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Coverage Amount Limit

ELIGIBILITY QUESTIONS:

Within the past 12 months, have you had, been told you have, or been treated for Cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, stroke (CVA), heart bypass surgery, angioplasty, stent insertion or more than one transient ischemic attack (TIA)?*

Yes

Within the past 12 months, have you had, been told you have, or been treated for Circulatory problems in the legs and/or feet (peripheral arterial or vascular disease)?*

Yes

Within the past 12 months, have you had, been told you have, or been treated for Chronic kidney disease, or been investigated or been advised to be investigated for polycystic kidney disease (PKD), or have a family history of PKD and have not been investigated?*

Yes

Within the past 12 months, have you had, been told you have, or been treated for Liver disease such as, but not limited to, cirrhosis or hepatitis (excluding Hepatitis A or B)?*

Yes

Within the past 12 months, have you had, been told you have, or been treated for Cancer including, but not limited to, leukemia and lymphoma (excluding basal cell carcinoma)?*

Yes

Are you under age 30 and have been diagnosed with diabetes (excluding gestational diabetes) or are undergoing investigation for diabetes or your blood sugar levels?*

Yes

Given that you answered yes to this question, you should apply for Deferred Elite Plans with a Maximum coverage of $75,000. Please speak with a YAM Insurance representative for more information.
Please proceed to the following page to conﬁrm Coverage Details

You’ve qualified for Deferred Life with a Maximum coverage of $75,000
Please proceed to the following page to qualify for coverage of Maximum $350,000 with Deferred Elite Plans.

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Coverage Amount Limit

ELIGIBILITY QUESTIONS:

Within the past 12 months, have you had, been told you have, or been treated for: bipolar disorder, schizophrenia or psychosis?*

Yes

Within the past three years, have you been treated for or received medical advice or counseling for the use of drugs or alcohol?*

Yes

Within the past three years, have you used narcotics or barbiturates (except as prescribed by a physician), heroin, psychoactive drugs, cocaine, crack or other similar agents?*

Yes

Are you age 54 or under and within the past three years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)? *

Are you age 54 or under and within the past three years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)?*

Yes

Are you age 55 or over and within the past two years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)? *

Are you age 55 or over and within the past two years, have you had treatment or surgery for or been diagnosed as having cardiac chest pain (angina), heart attack (myocardial infarction), coronary artery disease, heart bypass surgery, angioplasty, stent insertion, stroke (CVA) or chronic lung disease (excluding asthma)?*

Yes

Are you under age 55 with diabetes that was diagnosed more than 20 years ago and is currently treated with insulin? *

Are you under age 55 with diabetes that was diagnosed more than 20 years ago and is currently treated with insulin?*

Yes

Do you have diabetes that is currently treated with insulin and the prescribed dosage of insulin increased within the past six months?*

Yes

Have you ever had, been told you have, or been treated for diabetes and any of the following: coronary artery disease, peripheral vascular disease, tingling and loss of feeling in the extremities (neuropathy), amputation, retinopathy or stroke (CVA)?*

Yes

Within the past three years have you had, been told you have, or been treated for lung cancer?*

Yes

Within the past three years have you had, been told you have, or been treated for colon cancer?*

Yes

Within the past three years have you had, been told you have, or been treated for breast cancer, cervical cancer or uterine cancer?*

Yes

Within the past three years have you had, been told you have, or been treated for malignant melanoma?*

Yes

Within the past three years have you had, been told you have, or been treated for leukemia (all types), lymphoma or multiple myeloma?*

Yes

Do you plan to travel outside North America, the Caribbean (excluding Haiti), the United Kingdom or the European Union countries for more than 12 consecutive weeks in the next 12 months?*

Yes

Have you had a weight loss of 10% of body weight or more within the past 12 months other than due to intentional dieting?*

Yes

Is your weight outside the range shown for your height in the following table?*

Yes

NOTE: For females, deduct 5lbs. or 3 kg from the lower range for the given height

Height		Weight
4’8” — 4’10”	142 — 147 cm	79 — 185 lbs	36 — 84 kg
4’11” — 5’1”	148 — 155 cm	87 — 199 lbs	39 — 90 kg
5’2” — 5’4”	156 — 163 cm	94 — 215 lbs	43 — 98 kg
5’5” — 5’7”	164 — 170 cm	104 — 235 lbs	47 — 107 kg
5’8” — 5’10”	171 — 178 cm	115 — 260 lbs	52 — 118 kg
5’11” — 6’1”	179 — 185 cm	125 — 282 lbs	57 — 128 kg
6’2” — 6’4”	186 — 193 cm	139 — 305 lbs	63 — 138 kg
6’5” — 6’7”	194 — 201 cm	149 — 333 lbs	68 — 151 kg

Given that you answered yes to this question, you should apply for Deferred Elite Plans with a Maximum coverage of $350,000. Please speak with a YAM Insurance representative for more information.
Please proceed to the following page to conﬁrm Coverage Details

You’ve qualified for Deferred Elite Plans with a maximum coverage of $350,000
Please proceed to the following page to qualify for coverage of Maximum $500,000 with Simplified Elite Plans.

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Coverage Amount Limit

ELIGIBILITY QUESTIONS:

Within the past 12 months, have you been told you have, been treated for, or are you currently under investigation for multiple sclerosis?*

Yes

Have you ever had or been treated for cancer including, but not limited to, leukemia and lymphoma (excluding basal cell carcinoma)?*

Yes

Within the past six months, have you ever been told or have you been treated for diabetes?*

Yes

Within the past three years, have you been incarcerated or on probation for a criminal offence or are criminal charges now pending excluding a single DUI?*

Yes

Within the past two years, have you been involved in the operation of an aircraft as a pilot (scheduled commercial pilots excluded) or involved in any hazardous sports, or do you plan to do so within the next year?*

Yes

Within the past two years, has your driver’s licence been suspended or revoked, or have you had more than three moving violations within the past 12 months?*

Yes

Given that you answered yes to this question, you should apply for Deferred Elite Plans with a Maximum coverage of $500,000. Please speak with a YAM Insurance representative for more information.
Please proceed to the following page to conﬁrm Coverage Details

You’ve qualified for Simplified Elite Plans with a maximum coverage of $500,000
Kindly note that you are qualified for coverage of Maximum $1,000,000 with Preferred Plans / Preferred Elite Plans.

Please decide if you want to apply for Preferred Plans / Preferred Elite Plans*

Continue with Simplified Elite Plans

Wishes to apply for Preferred Plans / Preferred Elite Plans

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Coverage Amount Limit

ELIGIBILITY QUESTIONS:

The plan you may be eligible for will be determined by our underwriting department.

Preferred Plans

Minimum $50,000

Maximum $1,000,000

Have you ever been prescribed a medication that was for more than 30 days for a medical condition?*

Yes

Please advise the name of the prescription(s) and the nature of the medical condition there were prescribed for.

Explain*

Your physician’s name*

Reason for consult*

Address of your physician*

Date last consulted*

MM slash DD slash YYYY

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Coverage Amount Limit

ELIGIBILITY QUESTIONS:

The plan you may be eligible for will be determined by our underwriting department.

Preferred Elite Plans

Minimum $500,000

Maximum $1,000,000

What is your current height and weight? (Select your preferred unit combination)

Imperial

Height (inch)

Weight (lbs)

Metric

Height (cm)

Weight (kg)

Have two or more members of your immediate family (father, mother, brothers, sisters) ever had, been treated for, or been diagnosed with cancer, heart disease, stroke (CVA) or transient ischemic attack (TIA) before the age of 60?*

Yes

Please provide the details including age and cause of death or diagnosis of each.*

Within the past 24 months, have you used by any means (including electronic vaporizer or “vaping”), a substance or product containing tobacco, nicotine or marijuana?*

Yes

Smoker rates applicable.

Explain*

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Coverage Amount Limit

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Limit 1

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Limit 2

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Limit 3

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Limit 4

COVERAGE DETAILS

• Maximum two term insurance riders: - Riders can only be added if base is longer than rider term period (not equal).; - Term insurance riders are not available with Guaranteed Acceptance Life, Deferred Life or any 20 Pay plans.
• Complete Child Term Benefit questions Not available with:: - Guaranteed Acceptance Life; - Deferred Life
• Not available with:: - Guaranteed Acceptance Life; - Deferred Life; - Deferred Elite Life; - Deferred Elite Term

Permanent Insurance Plan*

Guaranteed Acceptance Life (Ages 18-75)

Permanent Insurance Plan*

Deferred Life (Ages 18-80)

Permanent Insurance Plan*

Deferred Elite Life (Ages 18-80)

Permanent Insurance Plan*

Simplified Elite Life (Ages 18-80)

Permanent Insurance Plan*

Preferred Life (Ages 18-80)

Permanent Insurance Plan*

Preferred Elite Life (Ages 18-80)

Permanent Insurance Plan*

Deferred Elite T100 (Ages 18-80)

Permanent Insurance Plan*

Simplified Elite T100 (Ages 18-80)

Permanent Insurance Plan*

Preferred T100 (Ages 18-80)

Permanent Insurance Plan*

Preferred Elite T100 (Ages 18-80)

Premium Payment Period*

Pay to Age 100

Premium Payment Period*

Pay to Age 100

20 Pay

Premium Payment Period*

Pay to Age 100

Amount of Insurance*

COVERAGE DETAILS

Term Insurance Plan*

Deferred Elite Term

Term Insurance Plan*

Simplified Elite Term

Term Insurance Plan*

Preferred Term

Term Insurance Plan*

Preferred Elite Term

Term Period*

10 Year (Ages 18-70)

Term Period*

20 Year (Ages 18-60)

Term Period*

25 Year (Ages 18-55)

Term Period*

25 Year Decreasing (Ages 18-60)

Amount of Insurance*

Optional Riders

10 Year Term ( Ages 18-70)

20 Year Term (Ages 18-60)

25 Year Term (Ages 18-55)

25 Year Decreasing Term (Ages 18-60)

Accidental Death Benefit (Ages 18-65)

Child Term Benefit (Ages 18-60)

Hospital Cash Benefit (Ages 18-65)

Amount (10 Year Term )*

Amount (20 Year Term)*

Amount (25 Year Term)*

Amount (25 Year Decreasing Term)*

Amount (Accidental Death Benefit )*

Amount (Child Term Benefit)*

$5,000

$10,000

$15,000

Amount (Hospital Cash)*

$25/day

$50/day

$100/day

Special Requests / Details

Any special requests, including premium and issue instructions, may be added here.

Third Party Determination

A third party is an individual or entity with an interest in a policy, but is not the Insured, Owner, Payor or trustee for a minor beneficiary. Examples include power of attorney and executor.

Is a third party involved with this application for insurance, or will a third party have the use of, or access to, the cash value of the policy?*

Yes

If YES, complete a separate Third Party Determination from CP011 for each third party.