Request Application for Life Insurance 1-888-767-6576
  • Thank you for your request application for life insurance. Upon completing this electronic request, one our licensed insurance agents will go over the details of your information and assist you in determining the suitability of the product you selected. Please note: This is NOT a life insurance application.
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  • Step 1 of 3 Contact Information
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  • First name*
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  • Last name*
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  • Phone*
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  • Email*
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  • Other phone (optional)*
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  • Province*
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  • Step 2 of 3 Health History
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  • Please answer these questions to the best of your knowledge. Your completed answers will help us find suitable solutions for your needs even if you have indicated "Yes" to some of the questions below.
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  • Please tell us about your...
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  • Height*
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  • Weight*
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  • Have you applied for life insurance in the last 90 days?
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  • Applied last 90 days?*
    No
    Yes
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  • Have you bought a life insurance policy within the last 5 years?
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  • Bought last 5 years?*
    No
    Yes
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  • Have you received disability benefits or any forms of government disability assistance within the last 6 months?
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  • Received disability?*
    No
    Yes
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  • In the past 5 years, have you been convicted of either reckless driving, driving while impaired, or received 3 or more moving violations or had your license suspended or revoked?
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  • Driving violations?*
    No
    Yes
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  • Do you have a history of any criminal conviction?
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  • Criminal offense?*
    No
    Yes
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  • Do you currently have a personal bankruptcy filing that has not been discharged or does not yet have a repayment plan established?
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  • Bankruptcy currently?*
    No
    Yes
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  • Do you intend to fly as a private pilot which includes balloons and gliders?
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  • Private pilot?*
    No
    Yes
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  • Do you intend to make more than 10 scuba dives in the next 12 months?
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  • Scuba diving?*
    No
    Yes
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  • Do you intend to: travel to any country shown on the Canadian travel advisory list , mountain climb, skydive, race a motorized vehicle, or engage in any hazardous activities?
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  • Dangerous hobbies?*
    No
    Yes
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  • Do you recall your last blood pressure reading?
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  • Systolic*
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  • Diastolic*
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  • Are you taking blood pressure medication?
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  • Blood pressure drugs?*
    No
    Yes
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  • Do you recall what your last cholesterol level was?
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  • Cholesterol*
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  • Are you taking cholesterol medication?
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  • Cholesterol drugs?*
    No
    Yes
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  • Any family (parents or siblings) diagnosed with cardiovascular disease (heart disease or stroke) or cancer before age 60?
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  • Family history?*
    No
    Yes
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  • Have you ever been asked to pay a surcharge over the standard rate, or been declined by any life insurance company?
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  • Declined or rated?*
    No
    Yes
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  • Has any doctor recommended any medical test or procedure that you have not yet completed?
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  • Uncompleted tests?*
    No
    Yes
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  • In the past 10 years, have you had or been treated for any of the following conditions?
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  • Conditions last 10 years?*
    None
    Alcohol Abuse
    Anxiety, ADD, ADHD or Depression
    Asthma
    Cancer (Skin Only)
    Drug Abuse or Addiction
    Gastric/Peptic Ulcers
    Recurrent Kidney Stones
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  • For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?
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  • Medical conditions?*
    None
    Alzheimer's
    Artery (Coronary) Disease
    Cancer (Other Than Skin)
    Colitis or Ileitis
    COPD
    Crohn's Disease
    Diabetes
    Emphysema
    Epilepsy
    Fibromyalgia
    Gout
    Heart Disease or Abnormal EKG
    Hepatitis or Liver Disease
    HIV
    Hypothyroidism
    Kidney Disease
    Leukemia
    Lupus
    Melanoma
    Mental Illness
    Mitral Valve Prolapse
    Multiple Sclerosis
    Parkinson's Disease
    Prostate Cancer
    Prostate Issues
    Rheumatoid Arthritis
    Sarcoidosis
    Sleep Apnea
    Stroke
    Vascular Disease
    Other
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  • Have you been diagnosed with any other health conditions not listed above?
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  • Other health conditions?*
    No
    Yes
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  • Thank you for answering the questions above. Upon completing a formal application, you will be asked these questions again, as required by the insurance companies. If there are other personal or health issues that might affect your premium, or approval, make sure these are added to the comments box below.
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  • Please provide addtional information or comments here...*
     
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  • Step 3 of 3 Consent
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  • I acknowledge that this is simply a request application for life insurance. By clicking on "I agree", I will be contacted by an IDC Insurance licensed agent to discuss the details of the information provided and to assist me in determining the suitability of the product I selected. I understand that this is NOT a life insurance application or a promise to issue a life insurance policy by IDC Insurance or the named insurance company displayed.
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  • Consent*
    I agree
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NEED HELP? Give us a call at 1-888-767-6576 © 2000-2017 INSURANCEDIRECTCANADA.ca, an e-commerce brand/property of IDC INSURANCE DIRECT CANADA INC. All rights reserved.

All product names, trademarks, and trade names are the property of their respective owners. The Insurance Council (BC, AB, SK, MB), Financial Services Commission (ON), Chambre de la Sécurité Financière (QC), The Superintendent of Insurance (NB, NL, PE, NS) are the provincial and federal authorities that regulate, supervise and enforce standards for life insurance professionals.

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