La Capitale - Online Application

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BASIC INFORMATION

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Sex_Quote

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Product Code

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Term Coverage

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Coverage Amount

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Monthly Premium

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Age

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Term, Permanent, I'm not sure

Language of correspondence

English

French

Indicate if this is:*

a new application

additional coverage to existing contract

Contract No.:

Should any contract resulting from this application be issued at the same time as another contract?*

Yes

If so, indicate the number of the other application

The number of the other application

General Information

Policyholder's Information

Last Name*

First Name*

Last name at birth (If different)

Date of birth*

Year

Month

Day

Sex

Male

Female

Sex

Male

Female

Marital status

Are you a Canadian citizen?*

Yes

Are you a permanent resident of Canada?

Yes

Country of birth*

In Canada since

YYYY slash MM slash DD

S.I.N.:*

S.I.N.:

Address (No., street, apt.)*

City

Province*

Postal code*

Country*

Email Address*

Home Phone

Work Phone

Extension

Cell Number *

Phone Number*

Purposed Insured's Information

Policyholder's Information*

The policyholder is a natural person

The policyholder is a company

The Policyholder is a natural person

Policyholder's information*

The proposed insured is the policyholder

Other

Last name

First name

Sex

Male

Female

Date of Birth

YYYY slash MM slash DD

Relationship to proposed insured

Marital status

S.I.N.

Occupation*

Address (No., street, apt.)

City

Province

Postal code

Country

Home Phone

Work Phone

Extension

Cell Phone*

Email*

Verification of Policyholder's Identity

Health insurance cards cannot be used in the following provinces: Ontario, Manitoba and Prince Edward Island. In Quebec, health insurance cards cannot be required for identification purposes but if a policyholder chooses to present one, it can be accepted.

Type of document*

Driver’s licence

Health insurance card

Passport

Other

Other photo I.D. issued by a federal or provincial authority

Document No.:*

Expiry date*

Year

Month

Day

Issuing authority*

Province or country of issue*

Verification of Tax Classification

Foreign Account Tax Compliance Act (FATCA)

Is policyholder a U.S. citizen or a U.S. resident for U.S. tax purposes?

Yes

If so, indicate the policyholder's U.S. taxpayer identification number (U.S. TIN).

Common Reporting Standard (CRS)

Is the policyholder a resident of a jurisdiction other than Canada or the United States for tax purposes?

Yes

Country

Identification number

Third Party Determination

Is policyholder acting in accordance with the instructions of another person (third party)?*

Yes

If so, complete the Third-Party Determination section of the Verification of an Individual’s Identity form (IND121E).

The Policyholder is a Company

Name (company name)

Address

City

Province

Country

Postal Code

Business Number

Place of registration

Name and title of authorized signatories:

GENERAL INFORMATION (CONT.)

Purpose of insurance

Personal insurance purpose

Mortgage insurance

Final expenses

Estate protection

Income protection

Other

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Insurance type:

Loan security

Key person

Buy out associates/redeem shares

Other

Is there an existing or planned agreement according to which a person other than the policyholder or a designated beneficiary will hold any rights to, titles to or interests in the contract to be issued as a result of this application?

Yes

If so, provide details:

Will a loan or financing be used for paying the premiums of the contract to be issued as a result of this application?

Yes

If so, provide complete details of the agreement terms and identify the parties to it:

Financial Information

The Proposed Insured's Financial Information

Employment status*

Employee

Self-employed

Student

Farmer

Retiree

At-home spouse

Unemployed

Employer's name*

Is your occupation with the armed forces, natural resources (forestry, mining, the oil or natural gas industries), rail, ﬁshing or marine transport (high seas, outside Canada) industries, performing arts (music, cinema, circus, etc.), bars and entertainment (bar employee, stunt performer, etc.), professional sports (athlete), aviation or professional scuba diving?*

Yes

Do you have to work at a height of more than 10 metres (35 feet)?*

Yes

Are you on disability?*

Yes

Occupation*

Annual gross income*

Other income

Source of other income

Total assets*

Total liabilities*

Have you declared bankruptcy in the last 5 years?*

Yes

Indicate the date you were discharged from bankruptcy, if applicable

Year

Month

Day

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Date

The Policyholder's Financial Information when a Company

Company's key activities:

% of the Proposed Insured's interest in the company

Please enter a number less than or equal to 100.

Company's assets:

Fair market value:

Company's liabilities:

Net profit of the current year:

Net worth:

Net profit for the previous year:

CHOICE OF COVERAGE

Main Coverage

Permanent Life Insurance - Non-participating Permanent Advantage

Individual - Premium payable

For 20 years

To age 65 (Minimum 25 years)

For Life

Insured amount

T100

Enhanced

Pure

Product

Share %*

Please enter a number from 0 to 100.

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

Contingent Beneficiary

Are there contingent beneficiaries?*

Yes

How many Contingent Beneficiaries do you have?*

Contingent Beneficiary 1

Last name*

First name*

Date of birth*

YYYY slash MM slash DD

Relationship to the proposed insured (in Quebec, relationship to the policyholder)*

Type*

Revocable

Irrevocable

Share %*

Please enter a number from 0 to 100.

Contingent Beneficiary 2

Last name*

First name*

Date of birth*

YYYY slash MM slash DD

Relationship to the proposed insured (in Quebec, relationship to the policyholder)*

Type*

Revocable

Irrevocable

Share %*

Please enter a number from 0 to 100.

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

Trustee for a Minor Beneficiary (Not Applicable in Quebec)

Last name of minor beneficiary

First name of minor beneficiary

Last name of trustee

First name of trustee

PERSONAL INFORMATION

Other Insurance In Force or Pending

Do you currently hold a life (LIFE), critical illness (CI), long-term care (LTC) or disability (DI) insurance contract or have a pending application for any of these types of insurance?

Yes

Contract type

Life

Critical illness (CI)

Long-term care (LTC)

Disability insurance (DI)

Insured amount

Accidental Death

Company name

Year and month issued

Year

Month

Day

Check if pending

Pending

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Year and month issued1

Insurance Type

Personal

Business

Will the insurance applied for replace the existing insurance contract?

Yes

@Add another

add another

Complete the prior notice of replacement if required. Please speak with your YAM Insurance representative for details.

Contract type

Life

Cirtical illness (CI)

Long term care (LTC)

Disability insurance (DI)

Insured amount

Accidental Death

Company name

Year and month issued

Year

Month

Day

Check if pending

Pending

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Year and month issued2

Insurance Type

Personal

Business

Will the insurance applied for replace the existing insurance contract?

Yes

#Add another

add another

Complete the prior notice of replacement if required. Please speak with your YAM Insurance representative for details.

Contract type

Life

Cirtical illness (CI)

Long term care (LTC)

Disability insurance (DI)

Insured amount

Accidental Death

Company name

Year and month issued

Year

Month

Day

Check if pending

Pending

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Year and month issued3

Insurance Type

Personal

Business

Will the insurance applied for replace the existing insurance contract?

Yes

Complete the prior notice of replacement if required. Please speak with your YAM Insurance representative for details.

Previous Insurance Coverage

Have you ever had a life (LIFE), critical illness (CI) or disability (DI) insurance application declined, deferred, modified, cancelled or rated with a higher premium?

Yes

Date

Year

Month

Day

Product Type

Life

Critical illness (CI)

Disability insurance (DI)

Company name

Decision

Reason

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add another

Date

YYYY slash MM slash DD

Product Type

Life

Critical illness (CI)

Disability insurance (DI)

Company name

Decision

Reason

%add another

add another

Date

YYYY slash MM slash DD

Product Type

Life

Critical illness (CI)

Disability insurance (DI)

Company name

Decision

Reason

Tobacco Use

In the last 12 months, how often have you smoked cigarettes or used any form of tobacco or nicotine (including marijuana/cannabis containing any tobacco or nicotine product) or used a substitute (nicotine gum or patch), electronic cigarette or vape device?*

Daily

Occasionally / Socially

Rarely

I stopped smoking in the last 12 months

I stopped smoking more than 12 months ago

I have never smoked

LIFESTYLE HABITS AND MEDICAL INFORMATION

Lifestyle Habits

Alcohol Use

In the last 12 months, have you consumed more than 15 alcoholic beverages per week (1 alcoholic beverage = 1 small bottle of beer, 1 six-ounce glass of wine or 1 ounce of spirits)?*

Yes

If so, complete the alcohol use questionnaire (IND031E). Please contact your YAM Insurance representative for a copy of this questionnaire.

In the last 5 years, has your consumption of alcohol changed?*

Yes

If so, complete the alcohol use questionnaire (IND031E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Have you ever received treatment or have you been advised to undergo treatment or to consult a physician regarding your consumption of alcohol?*

Yes

If so, please provide the dates and the reasons for the consultations and any other information*

Drug and opiate use

Do you currently use, or in the last 12 months have you used, marijuana, cannabis or hashish (1.5 g) more than 3 times per week?*

Yes

If so, complete the drug or opiate use questionnaire (IND021E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Do you use, or have you ever used, drugs or opiates or narcotics such as cocaine, LSD, barbiturates, amphetamines or other similar substances?*

Yes

If so, complete the drug or opiate use questionnaire (IND021E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Have you ever received treatment or have you been advised to undergo treatment or to consult a physician regarding your consumption of drug?*

Yes

If so, please provide the dates and the reasons for the consultations and any other information*

Driving record

Have you ever been charged with or found guilty of impaired driving?*

Yes

If so, complete the driving record questionnaire (IND020E). Please contact your YAM Insurance representative for a copy of this questionnaire.

In the last 5 years, has your driver’s licence been suspended or revoked?*

Yes

If so, complete the driving record questionnaire (IND020E). Please contact your YAM Insurance representative for a copy of this questionnaire.

In the last 5 years, have you been found guilty of 3 or more violations of the highway safety code?*

Yes

If so, complete the driving record questionnaire (IND020E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Criminal record

Have you ever been charged with or found guilty of any criminal offence?*

Yes

If so, specify the type, date, sentence and probation of each offence.*

Aviation

Do you plan to take part in or, in the last 2 years, have you taken part in any flights other than as a passenger?*

Yes

If so, complete the aviation questionnaire (IND024E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Hazardous sports

Do you plan to take part in or, in the last 2 years, have you taken part in mountain climbing (IND023E), extreme skiing (IND029E), extreme snowmobiling (IND029E), motor vehicle racing (IND025E), hang gliding (IND026E), skydiving (IND027E), scuba diving (IND028E), any other hazardous sport or activity (IND029E)?*

Yes

If so, complete the appropriate questionnaire. Please contact your YAM Insurance representative for a copy of this form.

Travel or residence abroad

Are you planning to travel or live in one of the following countries? Afghanistan, Burundi, North Korea, Iran, Iraq, Libya, Mali, Niger, Nigeria, Central African Republic, Somalia, South Sudan, Syria, the Republic of Chad, Yemen?*

Yes

In the next 2 years, are you planning to travel or reside abroad, other than in the following regions: United States, European Union, United Kingdom, Japan, Australia, New Zealand, the Caribbean (with an all-inclusive package)?*

Yes

Is this for work or business?*

Yes

If so, complete the travel and residence abroad questionnaire (INDO32E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Is it for a period of 12 weeks or more per year?*

Yes

If so, complete the travel and residence abroad questionnaire (INDO32E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Medical History

Have you ever consulted for, been treated for or shown signs or symptoms of any of the following conditions?

a) Cardiovascular System

High blood pressure?*

Yes

If so, indicate the number of drugs prescribed to treat this condition and if they are effective in managing it*

High level of cholesterol or triglicerides, chest pain, palpitations, irregular heart beat, heart murmur, acute rheumatic fever, heart attack, cerebrovascular accident, aneurysm or any other heart or blood vessel disorder?*

Yes

b) Respiratory System

Asthma, emphysema, shortness of breath, chronic bronchitis?*

Yes

If so, complete the respiratory disorders questionnaire (INDO14E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Obstructive sleep apnea?*

Yes

If so, indicate if you use cpap therapy for this condition, for how many years and the degree of severity of your symptoms (asymptomatic, mild, moderate, severe)*

Any other pulmonary or respiratory disorder?*

Yes

If so, complete the respiratory disorders questionnaire (INDO14E). Please contact your YAM Insurance representative for a copy of this questionnaire.

c) Gastrointestinal System

Hepatitis, cirrhosis of the liver, pancreatitis or other liver disorder?*

Yes

Ulcerative colitis, Crohn’s disease, hemorrhage, esophagus, stomach, gallbladder or intestine disorder?*

Yes

If so, complete the intestinal disorders questionnaire (INDO18E). Please contact your YAM Insurance representative for a copy of this questionnaire.

d) Genitourinary System

Urine abnormalities, kidney, bladder, prostate or genital organ disorder, sexually transmitted diseases or abnormal PAP tests?*

Yes

e) Endocrine System

Thyroid gland disorder or other endocrine condition?*

Yes

Diabetes?*

Yes

If so, complete the diabetes questionnaire (INDO15E). Please contact your YAM Insurance representative for a copy of this questionnaire.

f) Musculoskeletal System

Back or neck pain or disorder?*

Yes

If so, complete the back and neck disorders questionnaire (INDO13E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Arthritis, gout, bursitis, tendonitis, sprain or other muscle, ligament, bone or joint disorder?*

Yes

If so, complete the musculoskeletal disorders questionnaire (INDO12E). Please contact your YAM Insurance representative for a copy of this questionnaire.

g) Nervous System

Epilepsy?*

Yes

If so, complete the epilepsy questionnaire (IND134E). Please contact your YAM Insurance representative for a copy of this questionnaire.

Paralysis, multiple sclerosis, coma, Alzheimer’s disease, Parkinson’s disease, dizziness, loss of balance, optic neurosis, blurred vision, numbness, tingling or any other neurological disorder?*

Yes

h) Mental Health

Depression, burnout, insomnia, adjustment disorder, anxiety, fatigue/overwork, stress, postpartum depression or any other psychological, psychiatric or mental disorder?*

Yes

If so, complete the psychological disorders questionnaire (INDO17E). Please contact your YAM Insurance representative for a copy of this questionnaire.

i) Immune System

Lupus, AIDS-related complex, AIDS or test results indicating possible exposure to AIDS or HIV (Human Immunodeficiency Virus) or any other immune system disorder?*

Yes

j) Cancer or Tumor

Breast or ovarian cyst?*

Yes

If so, indicate the degree of severity (benign, malignant) and if you have already had a surgical procedure or excision for this condition.

Polyp?*

Yes

If so, indicate on which part of the body (nose, colon, uterus, other).

Leukemia, cancer, cyst, nodule, lymph node disorder, tumor (benign or malignant), other?*

Yes

If so, provide all details.

k) General

Anemia or other blood disease, skin disease or abnormal skin lesion, eye or ear condition or breast disorder (including lumps)?*

Yes

Have you ever consulted for been treated for or shown signs or symptoms of any other physical or psychological disorder not mentioned in the preceding questions?*

Yes

Pregnancy and Childbirth

Are you pregnant?

Yes

What is the due date?

Year

Month

Day

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Due date field

Have you previously had complications during a pregnancy or at childbirth (gestational diabetes, preeclampsia, cesarian section, postpartum depression, etc.)?

Yes

Physicians, Tests, and Medical Consultations

In the last 2 years, have you consulted a physician for a reason other than routine annual examinations or benign conditions (cold, flu, upper respiratory infection, etc.)?

Yes

If so, provide the dates and reasons for the consultations and your current state of health.

In the last 2 years, have you undergone routine tests (blood work, urinalysis, Pap test) or screening tests that have been recommended because of your age (mammography, colonoscopy, prostate exam)?

Yes

If so, were the results normal?

If not, provide the dates and details of any abnormal test results.

In the last 5 years, have you had an electrocardiogram, X-ray, CT scan, MRI, mammography, breast ultrasound, blood tests, follow-ups, screening or diagnostic tests?

Yes

If so, provide the dates, results and any other information.

In the last 5 years, have you ever consulted or been advised to consult a physician or a specialist or been advised to receive treatment following abnormal findings of a breast ultrasound, biopsy, mammography or Pap test?

Yes

If so, provide the results, diagnosis, date of diagnosis, dates and reasons for the consultations and any other information.

In the last 5 years, have you been admitted as a patient to a hospital or clinic?

Yes

If so, provide the name and address of the hospital or the clinic, the admission date and any other information.

Do you have signs or symptoms for which you have not yet sought medical attention, do you need to do so or have you been advised to consult a physician or specialist, undergo a treatment or surgery or have follow-up or diagnostic tests which have not yet been performed?

Yes

If so, indicate the signs and symptoms, the dates and reasons for the upcoming consultations and any other information

Disability or Absence From Work

In the last 5 years, have you been disabled or absent from work for a period of 4 consecutive weeks or more due to illness or injury?

Yes

If so, provide the dates, reasons, return-to-work date and any other information.

Medications

Are you taking any medication?

Yes

If so, specify.

LIFESTYLE HABITS AND MEDICAL INFORMATION (CONT.)

Additional Information

Height and Weight

Height

Height Type

Weight

Weight Type

Other than for childbirth, has your weight decreased by 4.5 kg (10 lb.) or more in the last 12 months?

Yes

If so, was the weight loss intentional?

Yes

If not, provide details.

How much did you lose?

Unit

Family History

Have any of the proposed insured's immediate family members, meaning father, mother, brother or sister, whether living or deceased, ever suffered from heart or vascular disease, cerebrovascular trauma, cancer, diabetes, polycystic kidney disease, multiple sclerosis, Alzheimer's disease, Parkinson's disease, Huntington's chorea, amyotrophic lateral sclerosis or any other hereditary disease before age 65?

Yes

Proposed Insured's name

Relationship to the proposed Insured

Name of disease (if cancer, specify type)

Age at diagnosis of the disease

Age if alive

Age at death

Cause of death

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Proposed Insured's name

Relationship to the proposed Insured

Name of disease (if cancer, specify type)

Age at diagnosis of the disease

Age if alive

Age at death

Cause of death

2Add another

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Proposed Insured's name

Relationship to the proposed Insured

Name of disease (if cancer, specify type)

Age at diagnosis of the disease

Age if alive

Age at death

Cause of death

Proposed Insured's name

3Add another

add another

Relationship to the proposed Insured

Age at diagnosis of the disease

Name of disease (if cancer, specify type)

Age if alive

Age at death

Cause of death

4Add another

add another

Proposed Insured's name

Relationship to the proposed Insured

Name of disease (if cancer, specify type)

Age at diagnosis of the disease

Age if alive

Age at death

Cause of death

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Proposed Insured's name

Relationship to the proposed Insured

Name of disease (if cancer, specify type)

Age at diagnosis of the disease

Age if alive

Age at death

Cause of death

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Is coverage required for a child under 18?

Yes

Supplementary Section for Proposed Insureds Under Age 18 (Proposed Insured Children)

Proposed Insured Child's Brothers and Sisters

Does the proposed insured child 1 have any brothers or sisters?

Yes

How many?

Does the proposed insured child 2 have any brothers or sisters?

Yes

How many?

Previous Insurance Coverage Of The Proposed Insured Child's Family Members

Proposed Insured Child 1

List below any life (LIFE), critical illness (CI) or disability (DI) insurance in force or pending on the lives of parents, brothers and sisters

Name of the proposed insured child’s family member

Relationship to the proposed insured child

Insurance type

Life

Critical illness (CI)

Disability insurance (DI)

Insured amount

Company name

Year issued

Untitled

Pending

Name of the proposed insured child’s family member

Relationship to the proposed insured child

Insurance type

Life

Critical illness (CI)

Disability insurance (DI)

Insured amount

Company name

Year issued

Untitled

Pending

Proposed Insured Child 2

List below any life (LIFE), critical illness (CI), or disability (DI) insurance in force or pending on the lives of parents, brothers, and sisters

Name of the proposed insured child’s family member

Relationship to the proposed insured child

Insurance type

Life

Critical illness (CI)

Disability insurance (DI)

Insured amount

Company name

Year issued

Untitled

Pending

Name of the proposed insured child’s family member

Relationship to the proposed insured child

Insurance type

Life

Critical illness (CI)

Disability insurance (DI)

Insured amount

Company name

Year issued

Untitled

Pending

Proposed Insured Child's Parents' Financial Information

Parents’ annual income:

Please enter a number greater than or equal to 0.

Parents’ net worth (assets-liabilities):

Please enter a number greater than or equal to 0.

Proposed Insured Child's Medical History

Has the proposed insured child ever consulted a physician for, been diagnosed with, or shown any signs or symptoms of any of the following conditions:

a) Cardiac malformation or other congenital abnormality?

Yes

b) Cerebral palsy, amyotrophic lateral sclerosis, muscular dystrophy, cystic ﬁbrosis or delay in physical or mental development?

Yes

Is the proposed insured child under 1 year old?

Yes

Was he or she born more than 4 weeks prematurely?

Yes

Additional Information

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Question No.

Please enter a number from 1 to 6.

Proposed insured's child name

Diagnosis, date of diagnosis, dates of consultations, reasons, results, medication or treatments, hospitalizations, surgery, names and addresses of physicians consulted or hospitals visited, current state of health or any other information.

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Question No.

Please enter a number from 1 to 6.

Proposed insured's child name

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Question No.

Please enter a number from 1 to 6.

Proposed insured's child name

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Question No.

Please enter a number from 1 to 6.

Proposed insured's child name

This field is hidden when viewing the form

Question No.

Please enter a number from 1 to 6.

Proposed insured's child name

This field is hidden when viewing the form

Question No.

Please enter a number from 1 to 6.

Proposed insured's child name

QUESTIONS FOR THE CONDITIONAL CERTIFICATE OF TEMPORARY INSURANCE

Have you ever consulted for, been treated for or shown signs or symptoms of the following:

There are no questions for you here

Cardiac or blood vessel disorders, including hypertension or high blood pressure, chest pain, angina, heart attack or stroke (cerebrovascular accident), cancer or tumor, AIDS (Acquired Immunodeﬁciency Syndrome), AIDS-related complex or any other immune system disorder, diabetes, chronic renal or pulmonary failure, chronic liver disease, multiple sclerosis, paralysis, Parkinson’s disease or Alzheimer’s disease?*

Yes

In the last 30 days, have you consulted or been treated by a physician or other practitioner for a reason other than pregnancy without complications or a minor condition for which no other follow-up visit has been scheduled or planned or for which the results are as yet unknown?*

Yes

In the last 3 years, have you had an application for individual or group life, disability, critical illness or long-term care insurance declined, deferred, modified, cancelled or rated with a higher premium?*

Yes

Have you ever been or are you currently on leave from work due to disability?*

Yes

Name

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