Life Application – Canada Life Insurance Quotes – Compare Save – Buy Life Insurance | IDC Insurance Direct Canada
Request Application for Life Insurance
  • 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.
    0
  • Step 1 of 3 Contact Information
    1
  • First name*
    2
  • Last name*
    3
  • Phone*
    4
  • Email Address*
    5
  • Other phone (optional)*
    6
  • Province*
    7
  • Step 2 of 3 Health History
    8
  • 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.
    9
  • Please tell us about your...
    10
  • Height*
    11
  • Weight*
    12
  • Have you applied for life insurance in the last 90 days?
    13
  • Applied last 90 days?*
    No
    Yes
    14
  • Have you bought a life insurance policy within the last 5 years?
    15
  • Bought last 5 years?*
    No
    Yes
    16
  • Have you received disability benefits or any forms of government disability assistance within the last 6 months?
    17
  • Received disability?*
    No
    Yes
    18
  • 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?
    19
  • Driving violations?*
    No
    Yes
    20
  • Do you have a history of any criminal conviction?
    21
  • Criminal offense?*
    No
    Yes
    22
  • Do you currently have a personal bankruptcy filing that has not been discharged or does not yet have a repayment plan established?
    23
  • Bankruptcy currently?*
    No
    Yes
    24
  • Do you intend to fly as a private pilot which includes balloons and gliders?
    25
  • Private pilot?*
    No
    Yes
    26
  • Do you intend to make more than 10 scuba dives in the next 12 months?
    27
  • Scuba diving?*
    No
    Yes
    28
  • 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?
    29
  • Dangerous hobbies?*
    No
    Yes
    30
  • Do you recall your last blood pressure reading?
    31
  • Systolic*
    32
  • Diastolic*
    33
  • Are you taking blood pressure medication?
    34
  • Blood pressure drugs?*
    No
    Yes
    35
  • Do you recall what your last cholesterol level was?
    36
  • Cholesterol*
    37
  • Are you taking cholesterol medication?
    38
  • Cholesterol drugs?*
    No
    Yes
    39
  • Any family (parents or siblings) diagnosed with cardiovascular disease (heart disease or stroke) or cancer before age 60?
    40
  • Family history?*
    No
    Yes
    41
  • Have you ever been asked to pay a surcharge over the standard rate, or been declined by any life insurance company?
    42
  • Declined or rated?*
    No
    Yes
    43
  • Has any doctor recommended any medical test or procedure that you have not yet completed?
    44
  • Uncompleted tests?*
    No
    Yes
    45
  • In the past 10 years, have you had or been treated for any of the following conditions?
    46
  • 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
    47
  • For what medical conditions have you EVER been diagnosed, treated or prescribed any medication?
    48
  • 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
    49
  • Have you been diagnosed with any other health conditions not listed above?
    51
  • Other health conditions?*
    No
    Yes
    52
  • 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.
    54
  • Please provide addtional information or comments here...*
    55
  • Step 3 of 3 Consent
    56
  • 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.
    57
  • Consent*
    I agree
    58

SPEAK TO AN AGENT

Call us toll-free
1-888-767-6576
Mon – Sat 9am – 6pm or
Click Here – We’ll Call You

How may we help you?

Don't find what you need? Please drop us a line...

Sending
NEED HELP? Give us a call at 1-888-767-6576 © 2000-2023 INSURANCEDIRECTCANADA.ca, an e-commerce brand/property of IDC INSURANCE DIRECT CANADA INC. All rights reserved.
Remarks

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.

I would like to...

Log in with your credentials

Forgot your details?