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• Filling out this form will give you a good start on learning the best rates from top insurance companies
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• PROVINCE*

  Province...British ColumbiaAlbertaSaskatchewanManitobaOntarioQuebecNew BrunswickNewfoundlandNova ScotiaPrince Edward IslandYukonNorthwest TerritoriesNunavut
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• MONTH*

  Birth month...JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
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• DATE*

  Birth date...12345678910111213141516171819202122232425262728293031
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• YEAR*

  Birth year...19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015
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• GENDER*

  Gender...FemaleMale
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• Please tell us what type of insurance and coverage amount you are looking to get quotes for
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• TYPE OF INSURANCE*

  Type of insurance...Term Life InsuranceMortgage Life InsurancePermanent Life Insurance
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• DESIRED AMOUNT*

  Desired amount...$10,000$25,000$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$900,000$1,000,000$1,100,000$1,250,000$1,500,000$1,750,000$2,000,000$2,500,000$3,000,000$4,000,000$5,000,000
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• ALTERNATE AMOUNT*

  Alternate amount...$10,000$25,000$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$900,000$1,000,000$1,100,000$1,250,000$1,500,000$1,750,000$2,000,000$2,500,000$3,000,000$4,000,000$5,000,000
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• TERM*

  Length of coverage...10 years or less15 years or less20 years or less25 years or less30 years or less35 years or less40 years or less
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• DESIRED AMOUNT*select your country

  Desired amount...$10,000$25,000$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$900,000$1,000,000
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• ALTERNATE AMOUNT*

  Alternate amount...$10,000$25,000$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$900,000$1,000,000
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• TERM*

  Length of payment...Pay within 10 yearsPay within 15 yearsPay within 20 yearsPay to age 65Pay lifetime
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• MORTGAGE AMOUNT*

  Mortgage amount...$50,000$75,000$100,000$125,000$150,000$175,000$200,000$225,000$250,000$300,000$350,000$400,000$450,000$500,000$550,000$600,000$650,000$700,000$750,000$800,000$900,000$1,000,000$1,100,000$1,250,000$1,500,000$1,750,000$2,000,000
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• TERM*

  Mortgage amortization...10 years or less15 years or less20 years or less25 years or less30 years or less35 years or less
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• HEALTH CLASS*

  Health category...Average healthGood healthExcellent health
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• TOBACCO USE*

  Tobacco use...Non-smokerSmoker
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• First name*
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• Last name*
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• Phone (###-###-####)*
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• Email Address*
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