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Name *
Email *
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(555) 123-4567
Birth Date
Jan
Feb
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Dec
1
2
3
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20
21
22
23
24
25
26
27
28
29
30
31
Gender
Male
Female
Have you ever smoked?
Yes
No
Cigarette
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Cigar
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Pipe
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Snuff
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Cigarello
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Chew
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Marijuana
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Prescribed
Never
Yes, in the last 12 months
Yes, but not in the last 1 yr
Yes, but not in the last 2 yrs
Yes, but not in the last 3 yrs
Yes, but not in the last 4 yrs
Yes, but not in the last 5 yrs
Yes, but not in the last 6 yrs
Yes, but not in the last 10 yrs
Yes, but not in the last 15 yrs
Yes, but not in the last 25 yrs
Province
Amount of Insurance
Face Amount
$ 25,000
$ 30,000
$ 35,000
$ 40,000
$ 45,000
$ 50,000
$ 55,000
$ 60,000
$ 65,000
$ 70,000
$ 75,000
$ 80,000
$ 85,000
$ 90,000
$ 95,000
$ 100,000
$ 125,000
$ 150,000
$ 175,000
$ 200,000
$ 225,000
$ 250,000
$ 275,000
$ 300,000
$ 325,000
$ 350,000
$ 375,000
$ 400,000
$ 425,000
$ 450,000
$ 475,000
$ 500,000
$ 550,000
$ 600,000
$ 650,000
$ 700,000
$ 750,000
$ 800,000
$ 850,000
$ 900,000
$ 950,000
$1,000,000
$1,250,000
$1,500,000
$1,750,000
$2,000,000
$2,250,000
$2,500,000
$2,750,000
$3,000,000
$3,500,000
$4,000,000
$4,500,000
$5,000,000
$6,000,000
$7,000,000
$8,000,000
$9,000,000
$10,000,000
$11,000,000
$12,000,000
$13,000,000
$14,000,000
$15,000,000
$16,000,000
$17,000,000
$18,000,000
$19,000,000
$20,000,000
$21,000,000
$22,000,000
$23,000,000
$24,000,000
$25,000,000
$26,000,000
$27,000,000
$28,000,000
$29,000,000
$30,000,000
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Additional Information
For all insurance questions and related matters please submit form or contact:
Jeffrey Comiskey,
Advisor
#128 – 4500 Blakie Road
London, ON N6L 1G5
Tel: (519) 473-4549
Toll Free: 1-866-943-4549
Fax: (519) 652-1627
Email:
jeffcomiskey@canadianterm.com
Website:
www.canadianterm.com
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