Online Insurance Application


Life Insurance	Canadian Life Insurance Quotes!	Online Life Insurance	Life Insurance Canada

Use this form to apply for life insurance, disability insurance, health insurance and more.

HONESTe Online Member Seal Click to verify - Before you buy!

Dear Applicant!

Welcome to our online application form. By now you already spoke to one of our advisors and decided on which policy to go with.

Now we need to make sure that the application process goes as smoothly and quickly as possible.

HERE IS WHAT YOU CAN DO TO HELP:

1. Please answer the few questions below

2. When the nurse calls you, make the appointment at your convenience

3. If she is taking a blood sample, make sure that you eat healthy a few days before the appointment (don't load up on KFC, donuts and coffee the day before). This will help you get the best rates.

4. Sign and return the Insurance company signature form to your advisor emailed you, the underwriter needs your authorization to work on your file.

5. Keep in mind that there is no cost for you for all these services, and you will be able to see your policy contract before accepting it.

Single Applicant Two Applicant
	Applicant 1	Applicant 2
Have you smoked cigarettes, cigars or any form of tobacco in the last 12 months?
Are you taking prescription medication for any of the following:
Have you applied at any other insurer in the last 2 years?
How much life insurance do you have now and what company?
Do you engage in any dangerous sports such as Scuba diving, parachuting motorcycle racing, piloting aircraft?
Has your drivers license been suspended in the last 3 years?
Are you a Canadian Citizen or Landed Immigrant?
Have you traveled outside of NORTH AMERICA (overseas) in the last 2 years or do you plan to in the next 1 year?
Have you ever had an application for life insurance declined, postponed, rated in any way?
Please elaborate on any "Yes answers"

FIRST APPLICANT DATA
First name	Initial	Last Name
Date of birth		Country of Birth
Occupation		Employer
Beneficiary name		Relationship
Drivers License number (or other ID such as Passport, citizenship or birth certificate number

Please tell us about the coverage you have chosen

Which Insurance Company have you chosen?
What amount of Insurance?
What term?

Mailing Address		City
Mailing Address		Province
Email address		Postal Code
Phone number	- -	Other phone	- -

PS * rest assured that any information you provide will be kept strictly confidential and we will not share it with anyone besides the Insurer!

Questions?

ned@insuranceshoppers.ca

Insurance Shoppers
203 Montee Outaouais Rd
Rockland, On, K4K 1G2
Phone : 800-683-5423 Fax : 905-248-5202

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Life Insurance

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