Term Life Insurance 

Term Life Insurance Quote
(Please submit one form per applicant.)

Yes, I want some term life insurance without a medical and as quickly as possible.
Please call me with the premium.

Has the Proposed Life Insured had or have ever been told he/she had or consulted a physician for a received treatment for any of the following:
Yes
No
A) Disorder of the heart or blood vessels including elevated or high blood pressure?
B) Chest pain, angina, heart attack, or stroke?
C) Cancer or tumour?
D) Acquired Immune Deficiency Syndrome (AIDS) AIDS Related Complex (ARCS) or any other immunological disorder?
E) Within the past two years, has the proposed Life Insured had any symptoms of, treatment for, any medical conditions that resulted in hospitalization for more than five days?
F) Has the Proposed Life Insured ever applied for life insurance which has been declined, rated or modified in any way?
G) Within the past 90 days has the Proposed Life Insured been unable to perform the normal duties of his/her occupation for fifteen or more working days because of health reasons?
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Smoked in last 12 months? Yes No  
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Coverage Amount  
Term  
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1405 Bishop Street, Suite 216, Montreal, Canada, H3G2E4
Tel: (514) 842-9001 - National Toll Free: (877) 842-3863

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