SSQ Simplified Insurance Company Inc (SSQ )

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Product Code

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Term Coverage

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Coverage Amount

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Monthly Premium

Proposed Insured

Title*

Mr.

Mrs.

Ms.

First Name*

Last Name*

Name at birth (if different)

Date of birth*

Year

Month

Day

Age*

Sex*

Male

Female

Sex*

Male

Female

Place of birth (country and city)*

Legal status in Canada:*

Canadian citizen

Permanent resident (holds a permanent resident card)

Work permit (attach a copy of the work permit and a letter from Citizenship and Immigration Canada confirming the permanent residence request)

Refugee

Other

Please send a copy of letter from Citizenship and Immigration Canada confirming the permanent residence to [email protected]

If you were born outside of Canada, complete the information below:

Arrival date*

YYYY slash MM slash DD

Residential Address

Civic number and street name*

Apt.

City*

Province*

Postal Code*

Phone Number*

Email Address*

General questions

1. a) Are you a Canadian citizen or a permanent resident?*

Yes

b) Do you currently live in Canada?*

Yes

2. Has a physician informed you that you have less than 2 years to live?*

Yes

Medical questions

In the last month, have you been diagnosed with COVID-19 or been in contact with an individual confirmed to have COVID-19?*

Yes

1. Are you currently confined to a wheelchair (that is, do you use a wheelchair for most of your moves on a weekly basis), bedridden (with the exception of pregnant women), hospitalized or do you need full-time care?*

Yes

Medical questions (Continued)

2. Have you ever had symptoms or been diagnosed with, received treatment, or consulted a physician for any of the following conditions:

a) Cerebrovascular accident (CVA) or transient ischemic attack (TIA)?*

Yes

i. Are you 60 years of age or less?*

Yes

ii. Have you had more than one incident?*

Yes

iii. Did your CVA or TIA occur less than 8 years ago?*

Yes

b) Heart attack, heart or coronary artery surgery, chest pain (angina), arrhythmia or any other disorder of the heart or blood vessels?*

Yes

c) Cancer or malignant tumor of the thyroid?*

Yes

i. Were you diagnosed in the last 10 years?*

Yes

ii. Did you have metastases and/or chemotherapy treatment?*

Yes

d) Cancer or malignant tumor other than thyroid cancer and basal cell carcinoma?*

Yes

e) Type 1 diabetes (insulin-dependent)?*

Yes

f) Type 2 diabetes?*

Yes

i. Are you under 41 years old?*

Yes

ii. Were you diagnosed over 15 years ago?*

Yes

iii. How often do you have follow-ups with your physician for your diabetes?*

Less than once per year

Once per year

2 times per year

3 times per year

4 times or more per year

iv. Has your diabetes medication been changed or increased in the last 6 months?*

Yes

v. Do you have complications, such as protein in the urine, neuromotor disorders, retinopathy, peripheral vascular disease?*

Yes

g) i. Hepatitis B or C, cirrhosis, liver failure, chronic pancreatitis?*

Yes

ii. Renal failure, polycystic kidney disease, any other chronic kidney disease?*

Yes

h) Anemia (other than an iron deficiency diagnosed as benign, treated and stable) or other blood disorder causing recurring embolisms, phlebitis and thrombosis?*

Yes

i) Schizophrenia, bipolar disorder, psychosis, suicide attempt or hospitalization for any psychological disorder?*

Yes

j) Systemic lupus, muscular dystrophy, Alzheimer's disease, Parkinson's disease, memory loss, loss of balance, multiple sclerosis, amyotrophic lateral sclerosis(ALS) or any other neurological disorder (excluding migraines investigated by a physician)?*

Yes

k) HIV test with positive results?*

Yes

l) Ulcerative colitis or Crohn's disease?*

Yes

i. Were you diagnosed in the past year?*

Yes

ii. In the last 5 years, have you had more than one attack or flare-up per year?*

Yes

Medical questions (Continued)

3. In the last 3 years, have you had symptoms or been diagnosed with, received treatment, or consulted a physician for a respiratory or pulmonary disorder (other than asthma, cold, flu or bronchitis, treated sleep apnea, pneumonia)?

Yes

4. In the last 12 months, have you been informed of an abnormal result on one of the following tests:

a) Imaging including ultrasound*

Yes

b) Mammography or any other breast imaging test*

Yes

c) EKG (electrocardiogram)*

Yes

d) Biopsy or pathology report results*

Yes

5. In the last 2 years, have you been informed of an abnormal result on one of the following tests:

a) Chest x-ray or pulmonary scan*

Yes

b) MRI or tomography (CT scan)*

Yes

c) Echocardiogram*

Yes

d) PSA (prostate specific antigen)*

Yes

6. In the last 12 months, have you been absent from work for more than 1 month for a psychological disorder or was your medication for a psychological disorder increased?

6. In the last 12 months, have you been absent from work for more than 1 month for a psychological disorder or was your medication for a psychological disorder increased?*

Yes

7. Have you consulted a physician for a disease or disorder that has not yet been diagnosed or for which the tests are ongoing or incomplete? Are you waiting on an investigation, result or operation?*

Yes

8. Have you received an abnormal test result, but have not yet consulted a physician?*

Yes

9. Do you have symptoms or health problems for which you have not yet consulted a physician, such as: breast mass or lump, shortness of breath, chest pain, unexplained weight loss, dizziness, loss of memory or balance, numbness, difficulty passing urine, blood in urine, rectal bleeding or any other problem not mentioned above?*

Yes

10. Have any members of your family, including father, mother, brother or sister, had familial adenomatous polyposis (or Gardner syndrome), Lynch syndrome, Huntington’s chorea or polycystic kidney disease?*

Yes

Questions about lifestyle

1. Have you ever received counseling, treatment or been advised to reduce your consumption or to undergo treatment for your alcohol or drug use?

1. Have you ever received counselling, treatment or been advised to reduce your consumption or to undergo treatment for your alcohol or drug use?*

Yes

2. In the last 10 years, have you been charged with or been convicted of a criminal offense or are you currently on probation?

2. In the last 10 years, have you been charged with or been convicted of a criminal offence or are you currently on probation?*

Yes

3. Is your driver’s license suspended at the moment?*

Yes

4. Have you ever been charged more than once for impaired driving?

4. Have you ever been charged more than once for impaired driving?*

Yes

5. In the last 2 years, have you received more than 3 driving offences?

5. In the last 2 years, have you received more than 3 driving offences?*

Yes

6. Does your profession fall under one of the following categories?

Journalism and photojournalism (international assignments)
Asbestos worker
Professional athlete
Military currently deployed or on order to be deployed
Commercial aviation (other than pilot for a major airline)
Worker in a bar/nightclub – striptease, escort

Does your profession fall under one of the following categories?*

Yes

7. In the last 2 years:

a) Have you flown as a private pilot or student pilot?*

Yes

b) Gone scuba diving deeper than 100 ft., gone parachuting (other than a single tandem jump) or hang gliding, participated in motor vehicle racing, been mountain climbing (with the exception of indoor climbing), out of bounds skiing or snowboarding including by helicopter or by snowcat, off-trail snowmobiling or done any other extreme sport?*

Yes

Questions about lifestyle (continued)

8. In the next 12 months, do you intend to travel or live outside of Canada:

a) for more than six (6) months?*

Yes

b) in a destination other than the following countries: the Caribbean/Antilles as part of an all-inclusive vacation, United States, Mexico, European Union countries, United Kingdom, Hong Kong, China, Japan, Australia, New Zealand, India?*

Yes

9. What is your tobacco use?
Cigarettes, cigars, cigarillos, electronic cigarettes/vaping, nicotine substitutes, or any other product containing tobacco or nicotine

I used*

In the last month

In the last 3 months

In the last 6 months

In the last 12 months

Between 1 and 5 years ago

Over 5 years ago

Never

My typical usage is/was

30 or more per day

20-29 per day

10-19 per day

1-9 per day

Less than 7 per week

Less than once per week

Less than once per month

10. What is your marijuana use?

I used*

In the last month

In the last 3 months

In the last 6 months

In the last 12 months

Between 1 and 5 years ago

Over 5 years ago

Never

My typical usage is/was

More than 2 times per day

More than 1 time per day

Once per day

Less than 7 times per week

Less than 3 times per week

Less than once per week

Less than once per month

11. Tell us about your drug use:
Heroin, cocaine, hallucinogens or any other drug not prescribed by a physician, except for over-the-counter medication

I used*

In the last month

In the last 3 months

In the last 6 months

In the last 12 months

Between 1 and 6 years ago

Over 6 years ago

Never

12. On average, how many of these alcoholic beverages do you drink per week:

Beer (341 ml)*

Wine (1 glass = 142 ml)*

Liquor/Spirits (1.5 oz)*

Question about height and weight

1. What is your height:*

Untitled*

ft.

2. What is your weight:*

Untitled*

lbs.

kg.