La Capitale Simplified - Online Application

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Step 1 of 5

20%

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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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Smoker

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Sex_Quote

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Plan Type

INSURED'S INFORMATION

First Name*

Last Name*

Last name at birth (If different)

Sex

Male

Female

Sex

Male

Female

Date of birth*

Year

Month

Day

Age at nearest birthday

S.I.N.*

S.I.N.

Address (number and street)*

City*

Province*

Postal code*

Phone Number*

Email Address*

Occupation*

POLICYHOLDER'S INFORMATION

Policyholder’s employer (current or past)

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.

I.D*

Driver's licence

Health insurance card

Passport

Other

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

Document No*

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Expiry Year

Expiry year

Expiry month

Issuing authority*

Province or country of issue*

Verification of Tax Classification

Foreign Account Tax Compliance Act (FATCA)

Is the policyholder a U.S. citizen or a U.S. resident for U.S. Tax purposes?*

Yes

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

U.S. TIN

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

Yes

If so, enter policyholder’s country and the foreign taxpayer identification number

Country

Identification number

Third Party Determination

Is the 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). Please contact your YAM Insurance representative for a copy of the form.

ELIGIBILITY

You don't need to take a medical exam when applying. To be eligible, you need to be between age 40 and 80 inclusive, have a permanent Social Insurance Number (one not beginning with the figure 9) and be able to answer NO to all the questions below. If you answer YES to any of the following questions, you are not eligible for Simplified Advantage.

1.a.) During the last two years, have you had an application for life insurance declined or deferred?*

Yes

1.b.) Do you currently have another life insurance application being assessed by La Capitale?*

Yes

1.c.) During the next 12 months, do you intend to submit an application for another life insurance product with La Capitale?*

Yes

2. Have you ever been diagnosed or undergone treatments, including taking medication, for the following: HIV, Acquired Immunodeficiency Syndrome (AIDS) or any AIDS-related complex, amyotrophic lateral sclerosis (Lou Gehrig’s disease), congestive heart failure, cystic fibrosis, Huntington’s disease, organ or bone marrow transplant, Alzheimer’s disease or dementia?*

Yes

3. Have you ever been diagnosed or undergone treatments for an incurable condition that has reduced your life expectancy to less than 24 months?*

Yes

4. Are you currently residing in a hospital, clinic, convalescent home or institution providing specialized care or are you confined to bed or a wheelchair, or have you been advised that this is required due to your present condition?*

Yes

5. During the last three years, have you been diagnosed, advised to undergo treatment or prescribed new medication or had the dosage of your medication changed, for angina, coronary bypass, myocardial infarction (heart attack), heart failure or cardiomyopathy, peripheral vascular disease, cerebrovascular accident (stroke), any blood disorder, other than iron-deficiency anemia, cancer (other than basal cell carcinoma), malignant tumor or leukemia, chronic kidney disease, a chronic respiratory condition requiring the administration of oxygen, liver disease (other than fatty liver), diabetic coma or insulin shock, multiple sclerosis or a primary immunodeficiency disease, attempted suicide, alcohol or drug abuse?*

Yes

6. During the last three years, have you suffered from high blood pressure (hypertension) not controlled by medication or monitored by a physician?*

Yes

7. With regard to the conditions mentioned in questions 2, 5 and 6, have you been investigated or have you undergone medical tests following which a diagnosis has not yet been made or have you been advised to do so, or have you noted symptoms for which you have not consulted a physician?*

Yes

8. Does your weight exceed the maximum weight indicated in the table below?*

Yes

HEIGHT		MALE		FEMALE
FEET	CM	LB	KG	LB	KG
4'10"–4'11"	147–151	195	88	180	82
5'0"–5'3"	152–160	208	94	191	87
5'4"–5'6"	161–168	230	104	213	97
5'7"–5'9"	169–175	250	113	229	104
5'10"–6'0"	176–183	270	122	249	113
6'1"–6'4"	184–193	291	132	274	124
> 6'4"	> 193	330	150	325	147

SMOKER STATUS

In the last 12 months, have you smoked cigarettes, cigarillos, cigars, a pipe, a bong, a hookah or used betel nut, snuff or marijuana (cannabis) containing any tobacco or nicotine product or used any other form of tobacco or a substitute such as gum, nicotine patch or electronic cigarette?*

Yes

INSURED AMOUNT SELECTION

See the Table of Monthly Premiums for premium rates.

Select the insured amount desired from the following minimums and maximums:

1- Insured age 40 to 70 when applying: $5,000 to $100,000

2- Insured age 71 to 80 when applying: $5,000 to $50,000

If you are age 70 or less, the insured amount, combined with any insured amount already in force under an existing Simplified Advantage coverage, may not exceed $100,000. If you are age 71 or more, the insured amount, combined with any insured amount already in force under an existing Simplified Advantage coverage, may not exceed $50,000. If applicable, the portion of the premium corresponding to any amount in excess of the insurance coverage will be reimbursed. The insured amount is doubled in the event of accidental death before age 85.

Insured amount desired

INSURED AGE 71 TO 80 WHEN APPLYING : MINIMUM OF $5,000 MAXIMUM OF $100,000
Age when applying	Male		Female
Age when applying	Non-smoker	Smoker	Non-smoker	Smoker
40	$1.77	$2.55	$1.47	$2.06
41	$1.77	$2.56	$1.47	$2.07
42	$1.78	$2.57	$1.47	$2.08
43	$1.78	$2.59	$1.47	$2.09
44	$1.79	$2.60	$1.47	$2.10
45	$1.79	$2.61	$1.47	$2.11
46	$1.84	$2.75	$1.51	$2.19
47	$1.89	$2.89	$1.54	$2.27
48	$1.94	$3.02	$1.58	$2.34
49	$1.99	$3.16	$1.61	$2.42
50	$2.04	$3.30	$1.65	$2.50
51	$2.10	$3.52	$1.73	$2.65
52	$2.17	$3.74	$1.81	$2.80
53	$2.23	$3.96	$1.89	$2.96
54	$2.30	$4.18	$1.97	$3.11
55	$2.36	$4.40	$2.05	$3.26
56	$2.56	$4.70	$2.18	$3.44
57	$2.76	$5.00	$2.31	$3.62
58	$2.96	$5.30	$2.44	$3.81
59	$3.16	$5.60	$2.57	$3.99
60	$3.36	$5.90	$2.70	$4.17
61	$3.64	$6.31	$2.90	$4.43
62	$3.92	$6.71	$3.10	$4.69
63	$4.19	$7.12	$3.30	$4.95
64	$4.47	$7.52	$3.50	$5.21
65	$4.75	$7.93	$3.70	$5.47
66	$5.15	$8.42	$3.95	$5.85
67	$5.54	$8.90	$4.20	$6.22
68	$5.94	$9.39	$4.44	$6.60
69	$6.33	$9.87	$4.69	$6.97
70	$6.90	$10.67	$5.22	$7.47

INSURED AGE 71 TO 80 WHEN APPLYING : MINIMUM OF $5,000 MAXIMUM OF $50,000
Age when applying	Male		Female
Age when applying	Non-smoker	Smoker	Non-smoker	Smoker
71	$7.48	$11.46	$5.74	$7.69
72	$8.05	$12.26	$6.27	$8.46
73	$8.90	$13.16	$6.98	$9.07
74	$9.76	$14.07	$7.69	$9.68
75	$10.61	$14.97	$8.40	$10.29
76	$11.73	$16.42	$9.21	$11.38
77	$12.85	$17.86	$10.02	$12.47
78	$13.98	$19.31	$10.83	$13.55
79	$15.10	$20.75	$11.64	$14.64
80	$16.22	$22.20	$12.45	$15.73

BENEFICIARY INFORMATION

Please speak to your YAM Insurance representative if you have any questions on the beneficiary designation.

Full name of beneficiary

Date of birth

YYYY slash MM slash DD

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

Check one

Revocable

Irrevocable