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Client Name
Client Phone
Client Email
Age
Last
Nearest
Birth Date
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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25
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29
30
31
>
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
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1930
1931
1932
1933
1934
1935
1936
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1938
1939
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1941
1942
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1945
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1947
1948
1949
1950
1951
1952
1953
1954
1955
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1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
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1972
1973
1974
1975
1976
1977
1978
1979
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1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Gender
Male
Female
Tobacco use
Yes
No
Cigarette
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Cigar
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Pipe
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Snuff
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Cigarello
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Chew
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Marijuana
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Prescribed
Never
within 12 months
more than 1 yr ago
more than 2 yrs ago
more than 3 yrs ago
more than 4 yrs ago
more than 5 yrs ago
more than 6 yrs ago
more than 10 yrs ago
more than 15 yrs ago
more than 25 yrs ago
Province
British Columbia
Alberta
Saskatchewan
Northewest Territories
Yukon Territory
Nunavit
Manitoba
Ontario
Quebec
Nova Scotia
New Brunswick
Prince Edward Island
Newfoundland
All Provinces
Face Amount
Face Amount
$ 25,000
$ 30,000
$ 35,000
$ 40,000
$ 45,000
$ 50,000
$ 55,000
$ 60,000
$ 65,000
$ 70,000
$ 75,000
$ 80,000
$ 85,000
$ 90,000
$ 95,000
$ 100,000
$ 125,000
$ 150,000
$ 175,000
$ 200,000
$ 225,000
$ 250,000
$ 275,000
$ 300,000
$ 325,000
$ 350,000
$ 375,000
$ 400,000
$ 425,000
$ 450,000
$ 475,000
$ 500,000
$ 550,000
$ 600,000
$ 650,000
$ 700,000
$ 750,000
$ 800,000
$ 850,000
$ 900,000
$ 950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
$2,750,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
$11,000,000
$12,000,000
$13,000,000
$14,000,000
$15,000,000
$16,000,000
$17,000,000
$18,000,000
$19,000,000
$20,000,000
$21,000,000
$22,000,000
$23,000,000
$24,000,000
$25,000,000
$26,000,000
$27,000,000
$28,000,000
$29,000,000
$30,000,000
Premium Payment
Premium mode
Annual
Semi-Annual
Quarterly
Monthly
Product Type
1 year Term
5 year Term
10 year Term
15 year Term
20 year Term
25 Year Term
30 Year Term
35 Year Term
40 Year Term
Level term to 65
Level term to 70
Level term to 75
Unique Term
OptiTerm
Traditional Term 100
T100 20-Pay
Unique Term 100
Whole Life / Life Pay
Whole Life / Pay to 65
Whole Life / 25 Pay
Whole Life / 20 Pay
Whole Life / 15 Pay
Whole Life / Quick Pay
Unique Whole Life
Living Benefits
Single Person Funeral Plan
10 year Term
11 year Term
12 year Term
13 Year Term
14 Year Term
15 Year Term
16 Year Term
17 Year Term
18 Year Term
19 Year Term
20 year Term
21 year Term
22 year Term
23 Year Term
24 Year Term
25 Year Term
26 Year Term
27 Year Term
28 Year Term
29 Year Term
30 year Term
31 year Term
32 year Term
33 Year Term
34 Year Term
35 Year Term
36 Year Term
37 Year Term
38 Year Term
39 Year Term
40 year Term
CI / Term 10
CI / Term 15
CI / Term 20
CI / Term 25
CI / Term 30
CI / Term 65
CI / Term 70
CI / Term 75
CI / T100 - Life Pay
CI / T100 - Pay to 65
CI / T100 - 10-20 Pay
CI / Cond. limited Pay
CI / Decreasing
Comb Life & CI/25%
Comb Life & CI/50%
Comb Life & CI/75%
Select the Critical Illnesses that need to be covered by the quoted products:
Heart Attack
Cancer
Stroke
Alzheimer's Disease
Aortic Surgery
Aplastic Anaemia
Autism
Bacterial Meningitis
Benign Brain Tumour
Blindness
Cerebral Palsy
Coma
Congenital Heart Disease
Coronary Angioplasty
Coronary Artery Surgery
Cystic Fibrosis
Deafness
Dismemberment
Heart Surgery
Heart Valve Replacement
Kidney (Renal) Failure
Loss of Independence
Loss of Limbs
Loss of Speech
Major/Vital Organ Failure/Transplant
Motor Neuron /Lou Gehrig's Disease
Multiple Sclerosis
Muscular Dystrophy
Occupational HIV
Paralysis
Parkinson's Disease
Rett Syndrome
Severe Burns
Type 1 Diabetes Mellitus
Underwriting Risk
Elite
Preferred
Regular
Simplified
Guaranteed
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