To get a no-obligation quote for Term Life Insurance, please complete the following form and submit it to our office. Your quote will be e-mailed to you the next business day. Please note that we can only provide insurance for residents of Alberta, Canada.
Your preferred means of communication for contact and follow-up :
E-mail
Phone
E-mail address :
Daytime telephone number :
Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905 Ext. :
Home telephone number :
Area 204 250 289 306 403 416 418 450 506 514 519 604 613 647 705 709 780 807 819 867 902 905
Tell us about yourself...
Please Note : all fields must be completed for an accurate quote.
Name:
Address:
City:
Province:
Postal Code:
Sex
Male Female
Date of birth
(dd / mm / yyyy)
If you belong to a group insurance plan, enter the name of your group
Have you ever had your insurance cancelled or refused?
Yes No
When would you want this coverage to be effective?
Amount of coverage you want
$50,000 $100,000 $150,000 $200,000 Over $200,000
Tell us about your health...
Overall health
Good Poor
Do you smoke?
Did you stop smoking within the past year?
Is there anything else that we should know?
Your Privacy You are authorizing that we collect, use or disclose your personal information contained on this information form as well as any additional information that we may obtain about you and other listed beneficiaries based on the information you have disclosed to us, (for example confirming your claims history or checking with motor vehicle agencies), for the purpose of providing you with this quote. By submitting this information form you also confirm that you have obtained the permission of all other potential beneficiaries listed on this information form for the collection, use and disclosure of their Personal Information for the purpose of providing you with this quote. Submission of this form does not constitute an application for insurance. Do you consent? Yes No
Thank you for taking the time to fill out this form. Select the "Submit" button below and we will e-mail you a quote by the next business day. Our quote will include the coverages you selected. We will include the cost of popular optional coverages with our quotation.
* Coverage is subject to the insurer's underwriting policies.
** To learn more about the protection of your personal information, consult Privacy & Legal.
