General Life Insurance Application Request

Number of Insureds

Name *

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Identification – Type/Number/Expiry Date/Jurisdiction

Do You and Your Spouse Live at the Same Address

Do You Have Dependent Children?

Age of Children

Occupation/Employer Name

Annual Income

Approximate Net Worth

Approximate Outstanding Debts

Date of Birth

Height

Weight

Do You Have a Family Physician?

Name of Family Physician

Date of Last Physician Visit

Reason for Last Physician Visit and Details of Condition/Treatment (if any)

Spouse's Full Name

Spouse's Date of Birth

Address

Address Line 1

City

State / Province / Region

Postal Code

Spouse Identification – Type/Number/Expiry Date/Jurisdiction

Spouse's Occupation/Employer Name

Spouse's Annual Income

Spouse's Approximate Net Worth

Spouse's Approximate Outstanding Debt

Spouse's Height

Spouse's Weight

Does Your Spouse Have the Same Family Physician as You?

Spouse's Family Physician's Name

Spouse – Date of Last Physician Visit

Spouse – Reason for Last Physician Visit and Details of Condition/Treatment (if any)

Are Any of the Applicants on Any Prescription Medication?

Applicants Name/Medication Name/Medical Condition/Dosage/Length of Treatment

Are the prescriptions refillable?

Have Any of the Applicants Consumed any Nicotine, Tobacco, Alcohol or Cannabis Products in the Last 12 Months?

Applicants Name/Details of Daily/Weekly or Monthly Consumption Habits

Have Any of the Applicants Ever Received or Been Advised to Undergo Treatment or Counselling for Drug/Alcohol Abuse?

Applicants Name

In the Last 2 Years, Have Any of Applicants Used Unregulated Substances (Street Drugs)?

Applicants Name

Are Any of the Applicants Currently Pregnant?

Applicant Name / Weeks Pregnant

Have Any of the Applicants Had Any Diagnostic Tests Done in the Last 10 Years?

X-Ray, ECG, CT Scan, MRI, Blood/Urine Test…

Applicant Name/Dates/Diagnostic Outcome/Details of Condition (if any)

In the Last 10 Years, Have Any of the Applicants Been Hospitalized?

Name of Applicant/Date/Length of Visit/Diagnostic Outcome/Details of Condition (if any)

Have Any of the Applicants Ever had Symptoms of Any Chronic Cardiovascular Conditions

Stroke/CVA, Transient Ischemic Attack, Heart Attac, Angina, High Blood Pressure, Chest Pains, Palpitations, Heart Murmur, High Cholesterol…

Applicant Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Respiratory System Issues

Asthma, Chronic Bronchitis, Cystic Fibrosis, Emphysema, COPD, Sleep Apnea…

Applicants Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Digestive System Issues

Ulcerative Colitis, Chron’s Disease, Hepatitis, Chronic Pancreatitis, IBS….

Applicant Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Chronic Issues with the Kidneys, Bladder or Reproductive Organs

Applicant Name/Details of Condition/Treatment

Have Any of the Applicants Ever had Symptoms of Any Chronic Neurological Condition

Parkinson’s, Multiple Sclerosis, Chronic Headaches, Dizziness, Vertigo, Epilepsy, Paralysis…