ManuLife - YAM Life Insurance

"*" indicates required fields

Step 1 of 15

This field is hidden when viewing the form

Sex_Quote

This field is hidden when viewing the form

Type

Section 1 - General information

Purpose of policy

mortgage and debt insurance

Untitled

Income and family protection

Untitled

Business loan collateral

Untitled

key person

Untitled

estate preservation

Untitled

buy-sell

Untitled

Estate Bond

Untitled

Insured Retirement Program (IRP)

Untitled

Other

Please explain

Preferred Language

What is your language preference?

English

Français

You request that the contract and all other documents and correspondence relating to your policy be in English.

Vous demandez que le contrat et tous les documents et la correspondance y afférents soient en français.

Section 2 - Information About the Person to be Insured

In this section, you and your refer to the person to be insured. The questions must be answered by the person to be insured. If the person to be insured is a minor, the minor’s parent or guardian (tutor, in Quebec) must provide the information on their behalf.

We use the information you provide in this application to determine whether or not you are eligible for coverage and to establish the premium rates for the coverage you’re applying for. If you misrepresent any facts or the information you provide is not current, correct, and complete, we can cancel any policy we have issued on the basis of the information you provided.

If your application qualifies, we use the email address you provide in this section to send a copy of your application and any other policy documents we need you to electronically review, sign and return. We use the cell phone number you provide in this section to send the authentication codes you need to open the documents. You must tell us if your contact information changes.

Legal Name

First Name*

Middle initial

Last Name*

Previous name

Date of birth*

Day

Month

Year

Sex*

Male

Female

Sex*

Male

Female

Address (Number and street)*

Unit

City or town*

Province*

Postal Code*

Number of years at this address*

Preferred contact number*

Place of birth (province and country)*

Email Address*

Cell phone number *

Phone Number*

Are you a Canadian citizen or do you have permanent resident status?*

Yes

Previous country of residence*

Your current immigration status in Canada*

When did this status come into effect?*

DD dash MM dash YYYY

c) Have you applied for permanent resident status*

Yes

d) Are you a domestic worker under a special immigration program to work as "live-in" caregiver or nanny?*

Yes

e) Are you a foreign-trained physician under a provincial program?*

Yes

f) Are you a skilled worker under either federal or special provincial nominee immigration program?*

Yes

Section 3 - Policy Ownership

In this section, you and your refer to the policy owner. The questions must be answered by the owner of the policy. The owner must be a resident of Canada, as defined for Canadian income tax purposes. Note that the owner must sign for all changes to the policy that you request in the future.

If your application qualifies, we use the email address you provide in this section to deliver your policy contract and any other documents we need you to electronically review, sign and return. We use the cell phone number you provide in this section to send the authentication codes you need to open the documents. You must tell us if your contact information changes.

Social insurance number*

Policy Owner

Same as Insured

First name*

Middle initial

Last name*

Legal name (first, middle initial, last)*

Date of birth*

Day

Month

Year

Sex*

Male

Female

Social insurance number*

Relationship to person to be insured

Unit

Address (Number and street)*

This field is hidden when viewing the form

Home address*

City or town*

Postal code*

Province*

Email Address*

Cell phone number*

Section 4 - Beneficiary Information for Life Insurance

4.1 – Beneficiaries – Person to be insured

How many Primary Beneficiaries do you have ?*

Beneficiary 1 Name*

Relationship*

Type*

Revocable

Irrevocable

Share Percentage*

Beneficiary 2 Name*

Relationship*

Type*

Revocable

Irrevocable

Share Percentage*

Beneficiary 3 Name*

Relationship*

Type*

Revocable

Irrevocable

Share Percentage*

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

Secondary beneficiaries (called subrogated beneficiaries in Quebec)

How many Secondary Beneficiaries do you have ?*

Beneficiary 1 Name*

Relationship*

Type*

Revocable

Irrevocable

Share Percentage*

Beneficiary 2 Name*

Relationship*

Type*

Revocable

Irrevocable

Share Percentage*

Beneficiary 3 Name*

Relationship

Type*

Revocable

Irrevocable

Share Percentage*

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

4.3 Trustee for minor beneficiaries (not applicable in Quebec)

Complete this section if a beneficiary you’ve named above is a minor. By completing this section, you agree that any benefit that becomes payable to a minor beneficiary will be paid to the trustee to hold in trust for the child until the child comes of legal age.

How many Minor Beneficiaries do you have ?*

Name of minor beneficiary 1*

Name of trustee*

Relationship of trustee to beneficiary*

Name of minor beneficiary 2*

Name of trustee*

Relationship of trustee to beneficiary*

Name of minor beneficiary 3*

Name of trustee*

Relationship of trustee to beneficiary*

Section 5 - Personal Information

In this section, you and your refer to the person to be insured. The person to be insured must complete this section.

5.1 Residency and travel

a) Do you expect to change your country of residence?*

Yes

If yes, provide details, including where you intend to move, when you are moving, why you are moving, and if your occupation is changing tell us what your new occupation will be.*

b) Do you expect to travel outside Canada and the United States within the next 12 months?*

Yes

If yes, will you be travelling to a Caribbean or Mexican resort for less than four weeks, or travelling by cruise ship?*

Yes

Do you have any other travel plans?*

Yes

Countries and cities you will visit*

Length of stay in each*

Purpose of travel for each trip (Select all that apply) #1*

For business

As a tourist

To visit family

Other

If other, please mention the purpose of travel

Countries and cities you will visit

Length of stay in each

Purpose of travel for each trip (Select all that apply) #2

For business

As a tourist

To visit family

Other

If other, please mention the purpose of travel

Countries and cities you will visit

Length of stay in each

Purpose of travel for each trip (Select all that apply) #3

For business

As a tourist

To visit family

Other

If other, please mention the purpose of travel

5.2 Smoking and tobacco use

In the last 15 years, have you used or smoked any of the following?

a) Cigarettes*

Yes

Provide details including average amount used, how often, length of time used and the last date used*

b) Any form of marijuana (such as hashish)*

Yes

Provide details including average amount used, how often, length of time used and the last date used*

c) Cigars*

Yes

Provide details including average amount used, how often, length of time used and the last date used*

d) Pipe*

Yes

Provide details including average amount used, how often, length of time used and the last date used*

e) Cigarillos*

Yes

Provide details including average amount used, how often, length of time used and the last date used*

f) Chewing tobacco*

Yes

Provide details including average amount used, how often, length of time used and the last date used*

g) Nicotine substitutes (such as gum or patches)*

Yes

Provide details including average amount used, how often, length of time used and the last date used*

h) E-cigarettes*

Yes

Provide details, including average amount used, how often, length of time used and the last date used*

i) Other (Example: betel nuts, water pipe)*

Yes

Provide details, including average amount used, how often, length of time used and the last date used (Example: betel nuts, water pipe)*

5.3 Alcohol and drug use

a) In the last 15 years, have you consumed alcohol?*

Yes

Do you currently drink alcohol?*

Yes

Number of Beer bottles*

Per

Number of wine glasses*

Per

Number of Liquor oz/ml*

Per

Descripe any past drinking behaviour

Why you stopped drinking?

b) In the last 15 years, have you used unprescribed drugs or experimented with drugs or narcotics such as ecstasy, cocaine, LSD, heroin, amphetamines, barbiturates, anabolic steroids or similar agents?*

Yes

Provide details, including what you used, how often, and the last time you used it.*

c) Have you ever been treated or counselled for alcohol or drug abuse, or has someone ever recommended that you seek treatment or counselling or reduce your alcohol or drug consumption?*

Yes

If yes, you will need to complete the alcohol usage section or drug usage section in Underwriting questionnaire, NN9434E, as applicable. Please contact your YAM Insurance representative for a copy.

5.4 Driving history

a) In the past two years, have you been charged with any motor vehicle or traffic violation (such as speeding, illegal lane changes or seatbelt violations)?*

Yes

This field is hidden when viewing the form

Question Number

Provide details, including the number of charges and convictions and the date of the last conviction.*

b) In the past five years, have you been charged with careless or dangerous driving or had your licence suspended or revoked?*

Yes

This field is hidden when viewing the form

Question Number

Provide details, including the number of charges and convictions and the date of the last conviction. In the case of a licence suspension or revocation, provide details, including the date the licence was suspended or revoked.*

c) In the past 10 years, have you been charged with refusing a breathalyzer test, or operating a motor vehicle either while impaired by alcohol or drugs or with a blood alcohol level over the legal limit?*

Yes

This field is hidden when viewing the form

Question Number*

Provide details, including the number of charges and convictions and the date of the last conviction.*

d) Do you have a driver's licence?*

Yes

Driver's licence number*

Where it was issued?*

If you live in B.C., Manitoba, Quebec, N.W.T. or Yukon, and a motor vehicle record is required, you must also complete a Motor vehicle record authorization form. Please contact your YAM Insurance representative for a copy.

5.5 Other Information

a) Have you ever had an application for life, disability, critical illness or long term care insurance declined, rated, postponed, cancelled or modified in any way?*

Yes

This field is hidden when viewing the form

Question Number

Provide details, including the dates, name and type of coverage and the name of the insurance company.*

b) Have you ever been charged with any criminal offence?*

Yes

This field is hidden when viewing the form

Question Number

If yes, provide details, including the nature of each offence, the date charged, the sentence and the date the sentence and any probation was completed.*

c) In the past five years, have you flown in an aircraft as a pilot or do you expect to fly in an aircraft as a pilot?*

Yes

If yes, complete the applicable pages in Underwriting questionnaire, NN9434E. Please contact your YAM Insurance representative for a copy.

d) In the past five years, have you participated in a hazardous sport or activity or do you expect to participate in a hazardous sport or activity? (such as: scuba or skin diving - mountain climbing - ballooning - skydiving - heli-skiing - hang gliding - ultralight flying - racing of any kind - back-country skiing, snowboarding, or snowmobiling)*

Yes

If any other please indicate

If yes, complete the applicable pages in Underwriting questionnaire, NN9434E. Please contact your YAM Insurance representative for a copy.

e) In the past five years, have the person to be insured had any major financial difficulties, such as having pay garnished, petitioning for bankruptcy or declaring bankruptcy?*

Yes

This field is hidden when viewing the form

Question Number

Provide details, including the bankruptcy discharge date, if applicable.*

f) Is a licence or permit required to operate your business?*

Yes

Has any licence or permit ever been suspended or revoked, or has a regulating agency ever initiated a complaint against you?*

Yes

If yes, provide details.

g) For life insurance policies only, will the money to pay the premiums for this policy be borrowed from an individual, a bank or other institution?*

Yes

This field is hidden when viewing the form

Question Number

If yes, provide details*

h) For life insurance policies only, is there an existing or planned agreement that provides for anyone other than an owner identified in this application to obtain any legal interest in any policy resulting from this application?*

Yes

If yes, provide details*

5.6 Employment information

What is your occupation?*

How long have you worked for your current employer?*

Employer's name*

Employer's address*

Section 5 - Personal Information (continued)

5.7 Financial information

a) What is your annual earned income (within $10,000), including salary, commissions, dividends, bonuses and pension, within Canada?*

b) What is your annual income (within $10,000) from other Canadian sources, including interest and income from real estate, within Canada?*

c) If income is not generated from any of the above sources within Canada, tell us the household income.*

d) What is your personal net worth?*

e) Are you older than 70 and applying for insurance over $250,000?*

Yes

Canadian Assets Information

Value of primary residence*

Registered investments*

Other investments and holdings*

Canadian Liabilities Information

Mortgage*

Other liabilities*

Section 6 - Height and Weight

In this section, you and your refer to the person to be insured. The person to be insured must complete this section.

Height*

Height type*

ft/in

Weight*

Weight type*

Has your weight changed by more than 10 pounds (4.5 kg) in the past 12 months?*

Yes

Provide details, including the amount your weight changed and the reason. If the change resulted from pregnancy, tell us your pre-pregnancy weight.*

Section 7 - Medical Information

In this section, you and your refer to the person to be insured. The person to be insured must complete this section. If you are providing medical information about a child to be insured, it is important that you have enough contact with the child to answer these questions reliably.

7.1 Doctor or clinic consultations

If you need additional space to describe your treatment, medications or information about doctor or clinic consultations, add these details in section 7.6.

Your regular family doctor or clinic

Do you have a family doctor or clinic that you use regularly?*

Yes

Name of doctor (first, middle initial, last) or clinic*

Address*

City or town*

Province*

Telephone number*

Date last consulted in person, by phone, or by internet*

Reason last consulted*

Name on file with doctor or clinic (if different than legal name)

Treatment or medication prescribed and results of any tests completed*

Your recent doctor or clinic consultations

If you do not have a regular doctor or clinic, or if you have consulted a different doctor or clinic in person, by phone, or by internet since the consultation listed above, provide details about your last consultation.

Name of doctor (first, middle initial, last) or clinic

Address

City or town

Province

Telephone number

Date last consulted in person, by phone, or by internet

Reason last consulted

Name on file with doctor or clinic (if different than legal name)

Treatment or medication prescribed and results of any tests completed

Section 7 - Medical Information (continued)

If your advisor will have medical information collected by a paramedical service, go to section 8

7.2 Your Family Medical History

a. Have either of your parents or a sibling been diagnosed before age 65 with any of the following conditions: heart disease, stroke or cancer?*

Yes

Unknown

b. Have either of your parents or a sibling ever been diagnosed with Huntington’s chorea, polycystic kidney disease, Parkinson’s disease, multiple sclerosis, Alzheimer’s disease, amyotrophic lateral sclerosis (also called ALS or Lou Gehrig’s disease) or other motor neuron disease, diabetes, hepatitis, kidney disorders or retinitis pigmentosa?*

Yes

Unknown

If you answered "yes" to any of the above questions, please provide the following details

Relative's relationship to you*

Condition or impairment (if cancer, provide details, including the type and location)*

Age at onset*

Relative's relationship to you

Condition or impairment (if cancer, provide details, including the type and location)

Age at onset

Relative's relationship to you

Condition or impairment (if cancer, provide details, including the type and location)

Age at onset

7.3 Your Medical History

IMPORTANT: Any reference to testing, tests, test results, or investigations excludes genetic tests. Genetic test means a test that analyzes DNA, RNA or chromosomes for purposes such as the prediction of disease or vertical transmission risks, or monitoring, diagnosis or prognosis.

a. Do you have, have you been treated for, or have you been told you have any of the following conditions?

1) High blood pressure*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors*

2) High cholesterol*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors*

3) Cancer, tumours, leukemia, polyps or skin lesions*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors*

4) Diabetes (including gestational diabetes and impaired glucose tolerance)*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors*

This field is hidden when viewing the form

Question Number

b. Have you ever had or been told you had or been investigated or treated for conditions involving any of the following:

1) Your heart and blood vessels, such as: angina, chest pain or shortness of breath, palpitations or irregular pulse, poor circulation, blood clots, claudication, peripheral vascular disease or peripheral artery disease, stroke or transient ischemic attack (TIA), bypass or angioplasty, heart attack (myocardial infarction), swollen ankles (other than due to pregnancy), cerebrovascular disease (CVA), heart murmur, pacemaker*

Yes

If any other, please describe

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors*

Section 7 - Medical information (continued)

c. Have you ever had or been told you had or been investigated or treated for conditions involving any of the following:

1) Your Nose, throat or lungs, such as: asthma, chronic bronchitis, sleep apnea, tuberculosis, chronic obstructive pulmonary disease (COPD), cystic fibrosis, emphysema, sarcoidosis*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

2) Your abdominal organs, such as: celiac disease, cirrhosis, colitis, Crohn’s disease, diverticulitis, gastrointestinal bleeding, gastrointestinal reflux, hepatitis (including active or carrier state), hiatus hernia, jaundice, irritable bowel syndrome, pancreatitis, liver disease, ulcer*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

3) Your kidneys, bladder, or reproductive organs, such as: abnormal Pap test bladder infection, kidney stone, nephritis, prostatitis or other prostate disorder, protein in the urine, urinary tract infection (UTI), uterine fibroids, polycystic kidney disease, sugar or blood in the urine, other kidney or bladder disorders, other reproductive disorder or sexually transmitted disease.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

4) Your breasts, such as: abnormal mammogram findings or biopsy, cysts, lumps, other physical changes*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

5) Your nervous system, such as: ALS or other motor neuron disease, Alzheimer's disease, cerebral palsy, cognitive impairment, coma, dementia, dizziness, Down syndrome, developmental delay, epilepsy, fainting or syncope, loss of speech, migraine headaches, multiple sclerosis, mental impairment, paralysis, Parkinson’s disease, post-concussion syndrome, seizures or convulsions, tremor, vertigo, bacterial meningitis.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

6) Your eyes or ears, such as: blindness, blurred or double vision, deafness, glaucoma, impaired hearing, impaired sight, labyrinthitis, optic neuritis, tinnitus.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

7) Your mental health, such as: anxiety, attempted suicide, burnout, depression, schizophrenia, other psychological, behavioral, emotional or eating disorder.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

8) Your glands or blood, such as: abnormal blood sugar, anemia, bleeding tendency, gout, hemophilia, lymph glands, thyroid disorders, other endocrine disorders.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

9) Your muscles or bones, such as: chronic fatigue, chronic pain syndrome, fibromyalgia, muscular dystrophy, rheumatoid arthritis or osteoarthritis, any injury or disorder of the muscles, bones, joints or spine causing any physical limitations or restrictions.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

10) Your connective tissue, such as: lupus, scleroderma.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

11) Your skin, such as: basal cell carcinoma, dysplastic nevus syndrome, dysplastic nevus, nevus or nevi, dermatitis, psoriasis, lesions, freckles or moles that have changed in size, colour or have bled.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

12) Your immune system, such as: HIV, AIDS.*

Yes

If any other, please describe below

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

This field is hidden when viewing the form

Question Number

d. Has anyone ever recommended that you be tested for exposure to AIDS or HIV (other than for routine testing for pregnancy, blood donation, immigration or insurance), or do you have any reason to believe you have been exposed to the virus?

Yes

This field is hidden when viewing the form

Question Number

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

e. In the past five years, have you:

1) Had any medical or diagnostic tests, such as ECGs, X-rays, CT scans, Pap test, MRI, or blood tests?*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

2) Had any illness or injury not already mentioned in this application?*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

3) Had any surgery, hospital care, treatment, medical examination, diagnostic test or counselling not already mentioned in this application or that has been recommended but is yet to take place?*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

4) Used any recommended medication not already mentioned in this application on a daily basis for more than three weeks (including prescription and non-prescription)?*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

5) Consulted a counselor, health care worker, physician or therapist?*

Yes

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

This field is hidden when viewing the form

Question Number

f. During the past 12 months, have you missed more than 15 consecutive days of work or school because of illness or injury? *

f) During the past 12 months, have you missed more than 15 consecutive days of work or school because of illness or injury?*

Yes

This field is hidden when viewing the form

Question Number

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

g. Are you currently taking any prescribed medication, herbal or holistic treatment, or are you under observation for any condition other than those you have already told us about? *

g) Are you currently taking any prescribed medication, herbal or holistic treatment, or are you under observation for any condition other than those you have already told us about?*

Yes

This field is hidden when viewing the form

Question Number

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

h. Are you currently disabled and unable to perform your regular occupation or regular activities? *

h) Are you currently disabled and unable to perform your regular occupation or regular activities?*

Yes

This field is hidden when viewing the form

Question Number

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

i. Are you aware of any symptoms or complaints for which you have not consulted a doctor or received treatment? *

i) Are you aware of any symptoms or complaints for which you have not consulted a doctor or received treatment?*

Yes

This field is hidden when viewing the form

Question Number

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.*

j. Are you pregnant?

j) Are you pregnant?

Yes

Tell us your due date and the name and address of the attending doctor or health care worker

1) What was your pre-pregnancy weight?*

Measure unit*

2) Have there been any complications with your pregnancy?*

Yes

This field is hidden when viewing the form

Question Number

Details, diagnosis if known, treatment history, testing dates, reason for tests, results of tests, recurrence and names and addresses of all attending doctors.

k. Do you wear any device or use any application that helps you monitor wellness, health or a specific condition? *

k. Do you wear any device or use any application that helps you monitor wellness, health or a specific condition?*

Yes

Section 7 - Medical Information (continued)

7.4 Children under age 2 to be insured

Complete this section only if the person to be insured is under age 2. To apply for a child rider, use section 7.5 instead.

Has the child had surgery or been hospitalized for more than 3 days at birth or later?

Yes

Was the child born prematurely (less than 36 weeks)?

Yes

Were there difficulties surrounding the birth or in the first six weeks after birth, congenital abnormalities, infectious disease or other health concerns?

Yes

Section 8 - Your Other Insurance Policies

Other than group insurance, are any people to be insured covered under other life, critical illness, disability, or long term care insurance policies? Also include policies that: lapsed within the past 90 days, were sold to a third party, or were issued in another country.*

Yes

* For long term care policies: Tell us the benefit amount and time period (for example, $75/day or $1,000/month).

Name of insurance company*

Policy Number*

Year issued*

Amount*

Please enter a number greater than or equal to 0.

Type of insurance*

lapsed or sold to a third party? (if applicable)*

Lapsed

Sold to a third party

Personal or business*

Personal

Business

Replacing*

Yes

Replacement form or LIRD completed, if applicable

Yes

+ add more

Name of insurance company*

Policy number*

Year issued*

Amount*

Type of insurance*

lapsed or sold to a third party? (if applicable)*

Lapsed

Sold to a third party

Personal or business*

Personal

Business

Replacing*

Yes

Replacement form or LIRD completed, if applicable*

Yes

+ add more

Name of insurance company

Policy number*

Year issued*

Amount*

Type of insurance*

lapsed or sold to a third party? (if applicable)

Lapsed

Sold to a third party

Personal or business*

Personal

Business

Replacing*

Yes

Replacement form or LIRD completed, if applicable*

Yes

+ add more

Name of insurance company

Policy number*

Year issued*

Amount*

Type of insurance*

lapsed or sold to a third party? (if applicable)*

Lapsed

Sold to a third party

Personal or business*

Personal

Business

Replacing*

Yes

Replacement form or LIRD completed, if applicable*

Yes

+ add more

Name of insurance company

Policy number*

Year issued*

Amount*

Type of insurance*

lapsed or sold to a third party? (if applicable)*

Lapsed

Sold to a third party

Personal or business*

Personal

Business

Replacing*

Yes

Replacement form or LIRD completed, if applicable

Yes

+ add more

Name of insurance company

Policy number*

Year issued*

Amount*

Type of insurance*

lapsed or sold to a third party? (if applicable)*

Lapsed

Sold to a third party

Personal or business*

Personal

Business

Replacing*

Yes

Replacement form or LIRD completed, if applicable*

Yes

In all provinces, if this application for insurance is to replace existing life insurance coverage, complete and attach the required replacement disclosure forms. In Quebec only, if this application for insurance is to replace existing critical illness insurance coverage, complete and attach the required replacement disclosure forms.

You must also complete all necessary forms to cancel the existing policy.

Have you applied for any other insurance that has not yet been issued? Include life, critical illness, disability, or long term care insurance.

Yes

Name of insurance company

Refrence number

Amount

Type of insurance

Personal or business?

Personal

Business

Name of insurance company

Refrence number

Amount

Type of insurance

Personal or business?

Personal

Business

Name of insurance company

Refrence number

Amount

Type of insurance

Personal or business?

Personal

Business