Free Critical Illness Insurance Quote

Please spend a few minutes to tell us a little about you so we can research the Critical Illness (CI) Insurance Market in Canada.

Step 1 of 4

Title

First Name*

Last Name*

Date of Birth (dd/mm/yyyy)*

Gender* Male Female

Height

Weight

Do you currently have a critical illness insurance policy? Yes No

Do you plan to replace this policy? Yes No

Coverage Required

Policy Length

Health Questions

Step 2 of 4

Did your biological parents or siblings, before they turned 65, have incidents of or die from heart disease, cancer, stroke or diabetes? Diabetes
Cancer
Heart Problem
Alcohol or Substance Abuse
Cholesterol
Asthma
Depression or Anxiety
Blood Pressure
Sleep Apnea
Other Significant Issues
Have you ever been treated for one of the following conditions? Diabetes
Cancer
Heart Problem
Alcohol or Substance Abuse
Cholesterol
Asthma
Depression or Anxiety
Blood Pressure
Sleep Apnea
Other Significant Issues

Lifestyle Questions

Step 3 of 4

Have you ever smoked Cigarettes?

Have you been treated for alcohol abuse or told to reduce your alcohol intake? Yes No

Have you flown in the past 2 years as a pilot, student pilot or crew member? Yes No

In the past 12 months have you travelled outside of Canada or the United States? Yes No

In the next 12 months do you have any plans to live or travel outside of Canada or the United States? Yes No

Do you engage or plan to engage in any hazardous or extreme sporting activities? Skin or scuba diving
Mountain climbing
Hang gliding
Heli-skiing
Parachute Jumping
Racing
Other

Do you have any Traffic Violations? Drving under influence (DUI)
Careless Driving
3+ Speeding Tickets

Do you require assistance with any of the following? bathing dressing moving in or out of bed or chair eating taking medications walking inside or outside using the telephone managing finances doing laundry transportation shopping meal preparation

Please let us know how to contact you.

Step 4 of 4

Phone*

Extension

Eve. Phone

Email*

Address

City

Province*

Postal Code

Country*

Thank you, for using our service.

You have taken an important step in finding the best life insurance policy available for your life insurance protection needs.

In addition to providing you with accurate rates we are licensed to give you the information and recommendations you may need.

One of our representatives will contact you shortly.